January/February 2022 Common Sense by American Academy of Emergency Medicine

COMMON SENSE VOICE OF THE AMERICAN ACADEMY OF EMERGENCY MEDICINE VOLUME 29, ISSUE 1 JANUARY/FEBRUARY 2022

Our Patients, Our Specialty: AAEM Versus Envision Page 9

President’s Message:

The Impact of Corporate Groups on Your Medical Practice…and What AAEM is Doing About it!

From the Editor’s Desk:

Are Emergency Physicians’ Brains Different?

Legislators in the News:

An Interview with Dr. Rich McCormick

AAEM/RSA President’s Message

An Interview with Dr. Dinesh Palipana

Young Physicians:

Now I am the Master: Transitioning from Learner to Teacher

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 AAEM/RSA Executive Director Madeleine Hanan, MSM Common Sense Editors Mehruba Anwar Parris, MD, Assistant Editor Kasha Bornstein, MD MPH MSC Pharm EMT-P, Resident Editor Stephanie Burmeister, MLIS, 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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COMMONSENSE

Regular Features President’s Message: The Impact of Corporate Groups on Your Medical Practice and What AAEM is Doing About it!.............................................................................................. 3 From the Editor’s Desk: Are Emergency Physicians’ Brains Different?........................................... 7 Legislators in the News: An Interview with Dr. Rich McCormick....................................................14 AAEM/RSA President’s Message: An Interview with Dr. Dinesh Palipana.....................................43 AAEM/RSA Editor: Insensible Losses.............................................................................................45 NEW COLUMN: Financial Wellness: A 5-Part Series on Managing Money Wisely: Financial Planning: An Important Part of Beating Burnout........................................................................23 Heart of a Doctor: The Parking Lot: End-of-Life Conversations in the Era of COVID-19................25 Foundation Contributors...............................................................................................................17 PAC Contributors............................................................................................................................19 LEAD-EM Contributors...................................................................................................................20 Upcoming Conferences.................................................................................................................22 Job Bank.........................................................................................................................................67

Featured Articles AAEM News: Our Patients, Our Specialty: AAEM versus Envision................................................... 9 AAEM News: Recent Corporate Practice of Medicine Case............................................................28 AAEM News: An Interview with US Congress Candidate Sam Alexander, MD................................29 Geriatrics Committee: This Virus Stinks: Two Personal Stories.....................................................31 Social EM & Population Health Committee: Outside the ED Walls: How One Ohio ED Responded to the Opioid Crisis by Opening a Clinic...................................................................33 Wellness Committee: Self-Compassion, Self-Valuation, and Boundary Setting in Emergency Medicine.....................................................................................................................................36 Wellness Committee: Stop Normalizing the Abuse of Residents...................................................38 Operations Management Committee: Where Have All the Nurses Gone? An Exploration of the Nursing Shortage and Proposed Solutions......................................................................39 Women in Emergency Medicine: A Q&A with Dr. Gillian Battino: A Physician Running for the US Senate for the State of Wisconsin.............................................................................41 Young Physicians Section: Now I am the Master: Transitioning from Learner to Teacher.............47 Critical Care Medicine Section: Captivating Capnography – The Basics of End-Tidal CO2.........49 AAEM/RSA Resident Journal Review: Is there a need for lumbar puncture to rule out subarachnoid hemorrhage if a head CT scan is negative?.........................................................53 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-0122-545 AAEM, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202 Tel: (800) 884-2236, Fax: (414) 276-3349, Email: info@aaem.org

The Impact of Corporate Groups on Your Medical Practice…and What AAEM is Doing About it!

AAEM PRESIDENT’S MESSAGE

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

s I write this message, we are scarcely into the New Year, and yet the hopes we voiced for 2022 as 2021 was coming to an end are all but vanquished, just as the hopes we had for 2021 when we were in December 2020 were similarly vanquished. We try to be positive. We try to be optimistic. We know that our mental health depends on our ability to generate positive energy and see the best in every situation. But emergency physicians are both scientists and public health leaders, and based on this training, we know that if we fail to identify a problem, we cannot begin to find solutions. Here is the problem, and it’s a problem that AAEM has been warning our colleague EM organizations about for decades with the passion of herald angels shouting the Christmas message to the world:

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Inadequate supply chain. When medicine is run as a business, it makes no sense to stockpile supplies in preparation for disaster. Supplies have expiration dates and throwing things out costs money. It also makes no sense in this model to ask physicians how to stay prepared for patient care. Folks with MBAs and MPAs know so much more about how to run a hospital system for profit. Let them make the decisions, using the models they use to predict how much of what items we need. In order to keep earning interest on our investments, let’s not be prepared too far in advance. We can always order more later. Enter COVID. Where is the PPE? The administrators who caused the problem don’t need to enter patient care areas, so they’re not impacted. But the physicians and nurses, the patients and families are the ones who paid the price. THEY DIED. WE DIED. We were told to reuse our PPE. Families were not permitted to visit. Patients died alone or with a compassionate nurse holding an IPad so a family could watch their loved one die on Zoom. The administrators sat in their offices and sent us pizza and told us we are heroes. In 2022, we have adequate PPE, but we are certainly lacking in other things. How many pharmacies and clinics are running out of point of care COVID test kits? There have even been instances of hospitals running out of test kits and asking physicians to use them judiciously. Even prior to COVID, drug shortages were seen more frequently than in previous years. When you run medicine as a business, you’re not prepared for the unexpected.

Here is the problem…The corporate practice of medicine is destroying the practice of medicine.” The corporate practice of medicine is destroying the practice of medicine. Private equity has no place in health care. What is good for private equity is not good for patients and not good for physicians. As a physician scientist, I cannot help but note the inverse correlation between the rise of private equity in medicine and the fall of health care quality and physician satisfaction. Join me as I look at what has happened to health care in correlation with the rise of the corporate practice of medicine.

Inadequate inpatient beds resulting in increased boarding times resulting in increased wait times in the ED. In a business, models are used to predict occupancy and an effort is made to operate at a set occupancy rate for maximum efficiency and maximum profit. Hotel chains can predict which cities will see peak occupancy during Mardi Gras and which during college graduations. But health care doesn’t work like that. No one was able to predict the COVID pandemic, Ebola, the anthrax scare, the bath salts trend. Being prepared

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for medical emergencies is not cost effective. Instead, administrators use the hotel model to plan for bed use. They use a business model to determine how many beds to open at what time of year. When the unexpected happens (Hello, this is emergency medicine!), they are not prepared. But they can sit in their offices and rely on the ED to board patients until beds are available, to downgrade unit patients to floor status, and sometimes to even send them home from the ED after their “inpatient hospitalization” has been concluded. They rely on us to run out into the waiting room and make sure no one dies, to pull patients with fast track issues into corners and stealthily exam them, to perform H&Ps in triage and then discharge from the waiting room. There is no concern in this business model for the dignity of the patients. There is no concern for the stress on the physicians, nurses, housekeepers, transporters, or any of their employees. There is no attention to the literature that shows that admitted patients who board in the ED have worse outcomes than those who are cared for on the inpatient floors or in the ICUs.

staff they can use most efficiently and cost effectively according to their prediction models, just like they stock the optimal amount of gauze pads. Make it work, Dr. Dear.

Decreased patient satisfaction. It is logical to us that people who are boarded in the ED for 72 hours, people who wait for an ED bed for five hours, people who are not

published surveys that document the distrust. Patients do seem to trust their physicians but they don’t trust the health care system. And too few of them have a primary care physician. And the patients most profoundly impacted are those who are most vulnerable and most at risk to start with: poor whites, Black and brown patients, those who don’t speak English, the uninsured, the underinsured, those living in rural areas and those with low health literacy or limited access to care.

Absence of due process.

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It is estimated that at least one third of emergency physicians are employed by a corporate medical group (CMG) and it is standard practice for CMGs to require physicians to waive their due process rights as a condition of employment. The result is, as we have said many times in these pages, that physicians cannot do the right thing for the patient, cannot speak up about patient safety issues, and cannot ask for the help that they need when there is understaffing and overcrowding, because they fear that their employment will be terminated, and they will have no recourse. You would have more rights if you worked as a cashier at Trader Joe’s than you have when you work as a physician for a CMG.

Well, step up family, because we need you now.”

Inadequate physician and nursing staffing in the ED. In the business model, this is also a supply chain issue. Managers keep on hand only what they plan to use in a specified time period. So, on a given shift, it is cost effective to have just the number of doctors and nurses who will see X patients per hour, and a business model is used to predict how many patients that will be. Make no mistake about it, you are no different to the corporation that employs you than a sack of frozen french fries is to the local McDonald’s. You are an item in the supply chain. Administrators are not there when a school bus is hit by a tractor trailer. You won’t see them down in the ED when eleven people are shot at a single event or when a building collapses. Instead, they stock the number of 4

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permitted to speak to the doctors and nurses about their family members, who can’t visit them, who are treated by staff wearing dirty PPE are not going to be happy campers. But if patient satisfaction scores are low, who is blamed? Not the administrators handing down the untenable policies. No, the doctors and nurses are taken to task and counselled on how they can increase their patient satisfaction scores. And while this is painful, it’s not as tragic as…

Decreased faith in the medical system. Since the proliferation of corporations practicing medicine, patients are expressing less faith in the medical system. This is evidenced by the frequency with which patients reject solid medical advice to mask, vaccinate, and socially distance. It is also evidenced by recently

Restrictive covenants. Again, the Academy has been saying for decades that there are no trade secrets in EM. What do we do if we figure out a new way to address a difficult emergency department complaint? We make a YouTube video so that everyone else will benefit. We have no private patients and the guys who think they are our private patients are usually the ones we’d like to pass on to another doc. When our waiting room is filled to capacity, we’d be happy to have folks go to a “competitor.” Yet if we are

AAEM PRESIDENT’S MESSAGE

terminated, or we want to quit to take a position that offers us something better, we can’t work within a given radius of our CMG. Did you go to medical school and through residency to have to live apart from your family or have to sell your house and move to a new city after being fired for speaking up about a patient safety issue? I didn’t think so.

Monopoly of jobs and services in certain cities and states. When the CMG owns every hospital in town there can be fee setting, price fixing, and salary determination based on their needs and wishes and their needs and wishes only. Read the interview with Georgia Congressional Candidate Dr. Rich McCormick in this issue. Monopolies are bad for employees and bad for customers. And they are worse for doctors and patients, who have much more on the line than being satisfied with the quality of your burrito and the service and cleanliness of the local restaurant.

Corporations hiring mid-level practitioners to replace physicians. They are cheaper. They save the corporation money and increase profits for the stockholders. Data shows that they over order and over consult, but this is a boon for the corporation. They can charge for all this! You and I know that it’s not a boon for the patient, who is now subjected to more procedures, all of which have attendant risks, and too many insignificant but abnormal test results that need to be chased, and more consultations that increase through put time in an already overburdened system. You and I also know that mid-levels have less than 10% of the clinical training of board certified physicians (in many cases, 500 hours compared to our 12,000 hours), and lack of clinical training and adequate supervision can only result in poorer patient outcomes, especially for the most vulnerable among us. The first officer is never allowed to fly the plane unless the licensed pilot is in the flight deck supervising her. Why? Because lives are at stake. Good morning, legislators who are allowing the corporate practice of medicine and independent practice by mid-levels: lives are at stake in the ED as well.

A proliferation of emergency medicine residency programs which is resulting in a predicted surplus of emergency physicians, and many say substandard training in many residencies. CMGs are now running residencies. The vast majority of residencies approved in the past few years are owned by CMGs. They benefit from the cheap labor of residents, in some cases supervised by nurse practitioners and PAs (because they are cheaper for the CMG to employ, see above) who may have less clinical hours than a senior medical student. It benefits the CMG to push out a glut of EPs since when supply exceeds demand, price falls. No one is paying attention to the quality of the training. This is a recipe for disaster as poorly paid, inadequately trained physicians are practicing in the most demanding field in medicine. What happens next is…

Predictions of less medical students and less prepared medical students applying to our residencies. Emergency medicine is, arguably, the most challenging of all specialties. We are the only physicians who see undifferentiated patients who don’t know their medical histories and medication lists or are unable to tell us this information by dint of their presenting problem. Emergency physicians must be able to simultaneously manage several critically ill, injured, and dying patients at the same time and make the right decision quickly, under duress and with limited information. It is essential therefore that the best and the brightest, the most decisive and the strongest medical students enter the specialty of emergency medicine. If the current trends continue this just isn’t going to happen. And we all eventually end up in the ED at some point in our lives, which means we’re all going to pay the price. (CMG executives: this includes you. Oh, I forgot. You make so much more money than we do that you can afford to have your own private concierge doctor. And we know that doctor is a physician, not a Doctor of Nursing Science or a PA with a PhD.)

Increased depression, burnout and suicide among physicians and other healthcare professionals. I don’t have to expound on this. You’re living it. I’ve depressed you by reminding you of things you already know, but here’s the take home message:

This is happening because we are allowing private equity and corporate medical groups to take over our profession. We need to stop this. And at AAEM, we are! You know how I always say, “AAEM is our members”? Well, step up family, because we need you now. And we need you, because you need us, and we are the only voice in EM with the courage to stand up to corporate medicine and private equity. The quick and simple things which we told you to do previously are first, look out for our announcements about HR 6910 and ensure that you and everyone you know contacts your members of Congress and tell them to support this bill, and second, to monitor your state legislature for the introduction of bills supporting independent practice for NPs and PAs. When you see this, let us know immediately so that we can help you educate your state legislators and prevent these bills from passing and endangering the health care of the people in your state. And now, I’m going to ask the most important thing. Renew your membership and get every EP you know to join AAEM. We need the power of your numbers and we need your membership money. I know it’s hard to ask. I’m the girl who felt guilty asking neighbors to buy Girl Scout cookies. But I don’t feel guilty asking for this. AAEM is funding perhaps the most remarkable lawsuit in the history of emergency medicine. We are funding a suit against Envision for the illegal corporate practice of medicine in the state of California. The AAEMPG has standing in this case because Envision displaced a private democratic group that was a member of the PG. This means that we are seeking no monetary compensation, so we will not “settle out of court.” We are taking this for the full ride. Our legal expenses are anticipated

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AAEM PRESIDENT’S MESSAGE

to be at least two million dollars, but if we prevail, the result will be a ban on Envision’s practice of medicine in California. This decision can then be used to ban other CMGs from practicing in California and then on to banning Envision and other CMGs from practicing medicine in other states. This is huge. This is expensive. If you are reading this, it is possible that your membership has expired. Please renew. Please ask everyone you know to join or renew. Staff and the Board will be contacting you if your membership has expired. Be nice to us. We exist to serve you, but we need your membership dollars. And, more than that, we need you to make a tax deductible contribution

to the AAEM Foundation—as much as you possibly can afford. This is an investment in your future. This is an investment in your career. If we lose this opportunity, we may never have another. By the time you read this, I will have reached out to the Presidents and Boards of every other EM organization. I will have asked them to support us with both statements of support and with contributions. I am challenging them to stand up for the integrity of emergency medicine practice and for the sanctity of the physician patient relationship. If you care about health care disparities, you will stand with us. If you care about workplace fairness for physicians, you will stand with us. If you care about

the future of emergency care in America, you will stand with us. I cannot state this any more clearly or any more emphatically. You must stand with us as we are standing for you.

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 800884-AAEM.

28 TH ANNUAL SCIENTIFIC ASSEMBLY Register Today for #AAEM22! aaem.org/aaem22

COMMON SENSE JANUARY/FEBRUARY 2022

FROM THE EDITOR’S DESK

Are Emergency Physicians’ Brains Different? Andy Mayer, MD FAAEM

mergency physicians are used to not knowing all of the facts. Our professional brain is trained to gather all of the immediately available data which can reasonably be obtained within the time constraints of the emergency department and then decide and act. This timeframe can be seconds or minutes but not usually more than a couple of hours. We do not have the luxury of expansive history gathering, data collection, discussion, and reflection. Every emergency physician has had to come to terms with the stressful reality of having to decide something really important without enough information. We make the decision to admit or discharge and then have to move on to the next patient. Just think for a second about how long you really deliberate on whether or not to admit the 45-yearold guy with chest pain with the normal EKG. You do not have the luxury of time in making decisions and this is the dilemma of the decision-making process which separates different types of physicians. Consider when you entered medical school and started your first clinical rotations and first felt the small but growing pressures and responsibility of “deciding.” Initially medical students are mostly information gatherers who find the information needed to help the decision makers on the team make the right decision. You as a young medical student had to decide what to present to your team and needed to try and emphasize the right points. You did not decide who needed admission or who was ready for discharge but you had responsibilities which allowed you to help with patient care and observe how decisions were made as a step towards accepting this responsibility yourself. You could mostly ere by omission by not knowing or not sharing a piece of information which would help in the decision process. As you moved along in your training and started seeing patients alone in a clinic or emergency department setting your level of responsibility grew. The level of supervision decreased and the level of responsibility increased. Some medical students can “decide” and move on more quickly than others. Did you notice the difficulty some of your fellow medical students had with making decisions? Some could present a simple abdominal case to your resident or staff on rounds in thirty seconds leading down the path which they thought was correct. These students had already “decided” for themselves what action needed to be taken and made the presentation which directed the decision makers towards that path. Others hampered by their indecisiveness stumbled through a patient presentation undecided on what to do next. This slowed down rounds and caused the real decision makers to dive deeper into the case as they sensed that they could not trust the

presentation and had to gather information on their own. This helped the indecisive medical student as they felt relieved of the responsibility due to the increased involvement of the team in their patient’s care but it also enforced this indecisive behavior. Could you tell who in your class would be drawn to emergency medicine as opposed to dermatology, pathology, or rheumatology? Some medical decisions need to be made fast and others allow copious time for deliberation while the 24-hour urine is running. Medicine draws in many types of personalities. Many cannot imagine standing in the OR for hours while other could not imagine sitting in a room talking to patients about their emotions for an hour. Some of your fellow medical students could not decide who needed a repeat CBC in the morning on their own and others felt

We have the unenviable task of making life changing decisions while being interrupted and rushed on a daily basis and yet we do it well.”

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FROM THE EDITOR’S DESK

comfortable making more important decisions and were able to speak to families and patients about serious topics. I sometimes wonder in this regard about emergency physicians and their brains. Did we train our brains to decide quickly or were we born with this ability? This is the classic nurture verses nature question. There is a great book about this dichotomy of decision making. It is called “Thinking, Fast and Slow” by Daniel Kahneman. It is well worth reading as you can think about where you stand in this regard. He divides decisions into two types. System 1 involves what you would think of as rapid decisions made after a limited amount of deliberation. Some might think of this as instinctual or emotional responses but the essence is making a decision rapidly without all of the information. System 2 thinking is what might be considered more thoughtful or deliberative. These decisions use more time and effort weighing the evidence and making a conscious decision and could be considered more logical. Naturally, one would think that emergency physicians would live in System 1 and rheumatologists live in System 2. However, is that true? I personally think that it is but I suspect that we drift back and forth between the two systems. We have cases where we decide and make a disposition in our head but then while explaining to Epic our medical decision making we slow down and rethink our decision and move into System 2. In essence we change our mind or think better of sending a certain patient home. That is fine and correct on an occasional basis but imagine an emergency department where the emergency physician goes back in on most patients and orders another round of tests to delay the decision. I think we all know an emergency physician who you had to follow on a shift who worked that way. You cringe when you look at the schedule as you will typically find the department a mess. Patients are signed out to you who already has a full set of labs and a CT back but an ultrasound or whatever was added on. In effect, the decision on admit or discharge has been deferred to you. We all know this is a medicolegal problem. Does this emergency physician use mostly System 2 and does not have the time they need to make a

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decision in a busy emergency department? Were they always this way or did something happen? I think that sometimes we are triggered to handle certain cases in System 2 due to a bad experience. Everyone has a soft and sore spot in their medical brain. You all know colleagues who work up certain complaints more thoroughly and slowly than their usual pace. If you press them on this there is always a story related to a patient. This certainly occurs right after a bad case. After a good doc misses a pulmonary embolus for example, every short of breath patient will get a CT angiogram or whatever the second level of evaluation entails to allow the distressed physician time to decide it is okay to send the patient home. However, these decision-making adjustments can last for years or your entire career. I had a partner who had the misfortune once of discharging the wrong middle aged man with atypical chest pain. He was initially paralyzed and took off of work for a week or so but then seemed fine. However, he had an anniversary type reaction and happened to be working on the one year anniversary of this visit with said patient. He became paralyzed that day with any patient with chest pain. He moved to System 2 and became stuck and ended up admitting every patient with chest pain that day. He recovered but our brains are remarkable things. You will find certain physicians who for the rest of their careers will do a sepsis type workup on any child with a high fever. When questioned about this behavior by a resident trying to do cost effective or evidence based medicine they can become defensive and evasive before they reveal their battle

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Our professional brain is trained to gather all of the immediately available data which can reasonably be obtained within the time constraints of the emergency department and then decide and act.” scar which led to this decision delay. If you ever come upon a fellow emergency physician who becomes paralyzed with indecision after a bad case you will immediately recognize the fact that without the ability to promptly decide that the emergency department stops functioning. We have the unenviable task of making life changing decisions while being interrupted and rushed on a daily basis and yet we do it well. Now we added Covid to this mix and many of us faced the daily question of what we were supposed to do with the Covid patient right in front of us. Dealing with a new and deadly virus with virtually no information and experience as to how to best deal with it is an unpresented challenge related to deciding what to do. Sending a middle-aged patient with an oxygen saturation of 94% who kind of looks sick or deciding not to intubate the very hypoxic patient with Covid was difficult. We had to fight System 1 with System 2 when our knowledge base was extremely low and ever changing. It made my brain hurt. Attending meetings early during Covid it was clear that all decisions were really temporary as our conclusions were usually at least partially wrong. Consider where you stand on this spectrum of decision making. Are “fast” emergency physicians the masters of System 1 and are “slow” ones always in System 2? Where is the right place on this spectrum from a medicolegal perspective? Can you change where you are on the decision making tree?

AAEM NEWS

Our Patients, Our Specialty: AAEM Versus Envision Robert McNamara, MD MAAEM

he AAEM suit against Envision (EmCare) is a momentous event for our specialty and our patients. Every AAEM member needs to understand this filing and to encourage their colleagues to join with us in fighting corporate control. The future of EM is at stake. AAEM is our best hope as no one else in EM has stepped forward on this. AAEM is asking the courts to invalidate the contractual scheme used by Envision to skirt the patient protections inherent to the prohibition on the Corporate Practice of Medicine (CPOM) as embodied in the CA Business and Professions Code §§ 2400 and 2052. This will be an expensive undertaking but it is the hill we must fight on for the soul of our specialty. Issues at stake include lay influence over the patient-physician relationship, as well as control of the fees charged, prohibited remuneration for referrals and unfair restraint of the practice of a profession. Simply put we are saying profits should not be put over patients. AAEM has filed suits in the past against corporate interests with favorable results but this litigation is significantly DIFFERENT! In this matter it is AAEM alone that is taking the risk. Unlike the prior cases, we do not have other parties involved who preferred settlement. In this matter we are asking the court to weigh in on the need to protect the public by preventing lay control of medical practice. We are not seeking monetary damages, this is for you and our patients.

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This will be an expensive undertaking but it is the hill we must fight on for the soul of our specialty.”

A key aspect of this filing is a challenge to Envision’s use of a sham professional association owned by a corporate physician executive to skirt the intent of the CPOM prohibition. We plan to argue that it is actually private equity (Kravis, Kohlberg and Roberts) that owns and controls the contract and believe the evidence will support that contention. In the recently concluded case of Brovont vs EmCare it was revealed that Dr. Gregory Byrne, a former Texas ACEP President, admitted to holding 275-300 professional entities in 20 states at any given time to enable this scheme.1 Doctors are allowing their licenses to be used to aid and abet the CPOM. Sadly, other EM physicians have also been complicit in the corporate takeover of our specialty. In fact, EmCare, the forerunner to Envision, was founded by Leonard Riggs, MD, the 1980 President of ACEP. All those who have drank the Koolaid that private equity is “good for EM” because they can help us fight the insurers had better look in the mirror. The alignment with PE by major EM organizations has severely tarnished our reputation with the public and Congress. Disturbingly, many now see us as greedy. Furthermore, the insurers via Sound Physicians owned by Optum a subsidiary of United Healthcare already own EM practices. If we don’t take up the banner of CPOM just how do the PE apologists propose will we stop Optum/UHC or other insurers from owning us? Our patients, our specialty. Now is the time for ALL of the bedside doctors to stand up and rally behind AAEM. Let us not relegate the future of EM to control by Wall Street and the insurance industry. Any EM doc who is not a corporate leader should join AAEM now. Thank you to those who already have.

Reference: https://u.pcloud.link/publink/show?code=BOl

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OUR PATIENTS, OUR SPECIALTY: AAEM VERSUS ENVISION

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David J. Millstein (SBN 87878) Gerald S. Richelson (SBN 267705) MILLSTEIN & ASSOCIATES 100 The Embarcadero, Penthouse San Francisco, CA 94105 Telephone: (415) 348-0348 Facsimile: (415) 348-0336 dmillstein@millstein-law.com grichelson@millstein-law.com Attorneys for Plaintiff: AMERICAN ACADEMY OF EMERGENCY MEDICINE PHYSICIAN GROUP, I.N.C.

SUPERIOR COURT OF THE STATE OF CALIFORNIA

COUNTY OF CONTRA COSTA

(Unlimited Jurisdiction)

13 14 15

AMERICAN ACADEMY OF EMERGENCY MEDICINE PHYSICIAN GROUP, INC., a Wisconsin Corporation,

16 17 18 19 20 21

Plaintiff, vs.

Case No.: COMPLAINT FOR UNFAIR BUSINESS PRACTICES (BUSINESS AND PROF. CODES § 17200 AND FOR INJUNCTIVE AND DECLARATORY RELIEF

ENVISION HEALTHCARE CORPORATION; a Delaware Corporation; ENVISION PHYSICIAN SERVICES L.L.C.; a Delaware Limited Liability Corporation doing business in California and DOES 1-100,

Defendants.

23 24 25 26 27 28

COMPLAINT FOR UNFAIR BUSINESS PRACTICES (BUSINESS AND PROF. CODES § 17200 AND FOR INJUNCTIVE AND DECLARATORY RELIEF - 1 10

COMMON SENSE JANUARY/FEBRUARY 2022

OUR PATIENTS, OUR SPECIALTY: AAEM VERSUS ENVISION

1 2 3 4 5 6 7 8 9

SUPERIOR COURT OF THE STATE OF CALIFORNIA

COUNTY OF CONTRA COSTA

(Unlimited Jurisdiction)

13 14 15

AMERICAN ACADEMY OF EMERGENCY MEDICINE PHYSICIAN GROUP, INC., a Wisconsin Corporation,

16 17 18 19 20 21 22 23

Plaintiff, vs.

Case No.: COMPLAINT FOR UNFAIR BUSINESS PRACTICES (BUSINESS AND PROF. CODES § 17200 AND FOR INJUNCTIVE AND DECLARATORY RELIEF

ENVISION HEALTHCARE CORPORATION; a Delaware Corporation; ENVISION PHYSICIAN SERVICES L.L.C.; a Delaware Limited Liability Corporation doing business in California and DOES 1-100, Defendants.

24 25 26 27 28

COMPLAINT FOR UNFAIR BUSINESS PRACTICES (BUSINESS AND PROF. CODES § 17200 AND FOR INJUNCTIVE AND DECLARATORY RELIEF - 1 COMMON SENSE JANUARY/FEBRUARY 20221

OUR PATIENTS, OUR SPECIALTY: AAEM VERSUS ENVISION

1 2

PARTIES, JURISDICTION, AND VENUE.

At all times mentioned herein, the American Academy of Emergency Medicine

Physician Group, Inc. ("AAEMPG") is a corporation based in Milwaukee, WI, incorporated under

the laws of Wisconsin. AAEMPG provides business and administrative services to physician

groups, including in California. Until August 2021, it provided such services to the emergency

medicine physician group at Placentia Linda Hospital, Placentia Linda Emergency Physicians,

Inc. AAEMPG is a subsidiary of the American Academy of Emergency Medicine, a physician

professional society, and is a provider of administrative and management services, (“PLEP”).

At all times mentioned herein, Envision Healthcare Corporation was a corporation

existing under the laws of the State of Delaware registered to do business in California. It operates

at least twelve Emergency Departments ("E.D.'s”) throughout California. Its head of operations

for California is in Walnut Creek, California.

At all times, Envision Physician Services L.L.C. was a Delaware Limited Liability

Corporation doing business in California, owned and managed by Envision Healthcare. Plaintiff

is informed and believes and alleges thereupon that Envision HealthCare Corporation and

Envision Physician Services L.L.C. are alter-egos of each other having common ownership and

no separate corporate identities.

Does 1-100, inclusive, are sued herein under fictitious names. Their true names

and capacities are unknown to the Plaintiffs. When the true names and capacities are ascertained,

the Plaintiff will amend by inserting their true names and capacities herein. Plaintiffs are

informed and believe and thereon allege that each of the fictitiously named Defendants

participated in the acts complained of herein and is the agent of all other defendants in undertaking

actionable conduct alleged herein. Some of these Does colluded with Defendants and acted as

their agents in doing the acts alleged herein.

This Court has personal jurisdiction over each Defendant because the acts of each

of the Defendants occurring in California in connection with Defendants' violations of Business

and Professions Code §§ 650, 2400, 2052, 16600, 17500, and/or the Unfair Competition Law,

Business and Professions Code § 17200.

COMPLAINT FOR UNFAIR BUSINESS PRACTICES (BUSINESS AND PROF. CODES § 17200 AND FOR INJUNCTIVE AND DECLARATORY RELIEF - 2 12

COMMON SENSE JANUARY/FEBRUARY 2022

OUR PATIENTS, OUR SPECIALTY: AAEM VERSUS ENVISION

Venue as to the Defendants is proper in this judicial district pursuant to the

provisions of California Business and Professions Code § 16750(a) and California Code of Civil

Procedure §§ 395(a) and 395.5.

This Court has personal jurisdiction over each Defendant as co-conspirators

because the causes of action arise under California law and the acts of any of the Defendants

occurring in California in connection with Defendants' violations of § 16600 and/or the Unfair

Competition Law under Cal. Bus. Prof. Code § 17200. No portion of this Complaint is brought

pursuant to federal law.

9 10

defendants in undertaking the acts alleged. II.

11 12

At all times mentioned herein, each Defendants was the agent of each other

CHOICE OF LAW.

California law applies to Plaintiff’s claims. The application of California law is

constitutional, and California has a strong interest in regulating the business practices of resident

corporations, deterring, and enjoining the commission of unlawful practices, and affording

restitution to those harmed by activities occurring in and emanating from California.

10.

California is the State in which Defendants violated California's prohibition on the

Corporate Practice of Medicine, offered unlawful kickbacks in exchange for patient referrals,

employed physicians on the condition they execute illegal restrictive covenants, and committed

unfair business practices including false advertising.

11.

Plaintiff was injured by conduct occurring in and emanating from California.

12.

Defendants have significant minimum contacts with California creating State

interests with all parties and the acts alleged herein. California's interests far exceed those of any

other state. III.

24 25

13.

INTRODUCTION.

The practice of medicine in California is subject to extensive regulatory control

designed to protect the health and safety of the public. The Corporate Practice of Medicine

Prohibition, Bus. & Prof. Code § 2400 et. seq., prohibits corporations, lay entities, or any non-

licensed persons or entities from practicing medicine, assisting in the unlicensed practice of

COMPLAINT FOR UNFAIR BUSINESS PRACTICES (BUSINESS AND PROF. CODES § 17200 AND FOR INJUNCTIVE AND DECLARATORY RELIEF - 3

Continue reading on page 57.

COMMON SENSE JANUARY/FEBRUARY 20221

LEGISLATORS IN THE NEWS

An Interview with Dr. Rich McCormick Lisa Moreno, MD MS MSCR FAAEM FIFEM — President, AAEM

r. Rich McCormick is an emergency physician from Georgia who is running for Congress from Georgia’s 6th Congressional District. Dr. McCormick took an active role in AAEM’s recent Health Policy in Emergency Medicine (HPEM) meeting in Washington, D.C. and he is a member of the Academy. His position on the corporate practice of medicine is aligned with AAEM’s clearly stated position and AAEM board members and HPEM attendees really enjoyed discussing these issues with him in person in October. At this critical time in the life of our specialty, Dr. McCormick agreed to an interview with me to explore some of these fundamental issues and his own decision to run for public office.

serve our country in the legislature? Health care is 20% of our federal budget and the emergency physician is an expert on what’s going on in health care in America. I have experience in the military that has shown me that government programs often result in waste. Our health care costs have increased by 10% and a single payer system will end up costing even more. As I had these important conversations, I realized that this was a logical move.

LM: What prompted you to change your focus of service from the clinical practice of EM to politics?

LM: So, Dr. McCormick, this line of discussion leads logically into my next question. What traits that make you an effective EP will you carry forward to make you an effective legislator?

RM: Well, you know I am still clinically active, even working night shifts. I feel this is an obligation I have to my community and my colleagues during the pandemic. But yes, there was a specific event that prompted my decision to run for public office. I had come up with a fair and reasonable solution to the problem of surprise billing. Special interest groups have the time and money to lobby the legislature, and their focus is on business, not patients. I decided to bring my ideas directly to the legislature in my home state of Georgia, and when I did, I watched a Republican who chaired the committee (despite what I believe is a conflict of interest due to his former employment with an insurance agency) fail to vet my ideas during the meeting. One of the other attendees told me, “If you’re not at the table, you’re on the menu. If you want to make a difference, you need to get involved. Are you willing to do that?” A consultant told me there was an open seat in Congress. This was a big move, so like any good member of the military and our specialty of emergency medicine, I got a consult from my wife and my buddies. They pointed out that I have the experience of being an emergency physician, a combat pilot, and an active member of my community. Who better to

RM: As emergency physicians, we know how to identify the problem. We witness failed policies daily, and we see the impact of these failed policies on our patients. Look at the practices in the health care and pharmaceutical industries. Patients are unable to afford basic medications such as insulin. Major hospital corporations are setting policies that interfere with the physician’s ability to do the right thing for the patient. These practices have come about as a result of government policies that favor corporations and pharmaceutical firms. A second thing we do well is taking leadership. We lead resuscitations, we advocate for patients, we make decisions about admission and discharge, and we own those decisions. My experiences in the ED and the military have provided me with these leadership skills, but beyond that leadership is the ability to work well under pressure. Emergency physicians and fighter pilots have the courage to make decisions in high stress situations. We are trained to maintain logic and calm, to weigh the facts even under stress, and to come up with the best response to the situation that is presented to us. We’re also very adept at dealing with unexpected events and pivoting when the situation changes or new information comes to light. We are bold and decisive. I can’t imagine better preparation for dealing with the Congressional environment.



We’ve made COVID political. And that’s ridiculous. This is not a political issue. This is an issue of public health.” 14

COMMON SENSE JANUARY/FEBRUARY 2022

LEGISLATORS IN THE NEWS



A healthy environment that fosters scientific inquiry and respectful discussion of the evidence and interpretation of the evidence is what will lead us forward in defeating this pandemic.” I’ve had some unique experiences being a white male conservative who went to medical school at Morehouse (author’s note: McCormick was elected president of his class at this HBCU medical school) and did residency at Emory. Those environments taught me a different kind of leadership. I learned the power of collective bargaining and I learned that it’s okay for people to disagree. We may have different opinions from colleagues we respect, and that’s okay. This is often what the environment is like in Congress.

would be better for patients if the position were filled by a physician. This makes the job market worse for us and the outcomes worse for patients. The government is regulating us into unfair business practices instead of allowing physicians, who are the experts in health care, to control medical practice and instead of allowing fair competition which would actually improve health care for all and ultimately make it more affordable. LM: As you know, AAEM is fully committed to maintaining the sanctity of the physician-patient relationship and we are opposed to the corporate practice of medicine. We also fully support the physician-led health care team and oppose independent practice by mid-levels. It’s great to hear that members like you want to bring this message to Congress and support workplace fairness. One of the other things about the practice of EM is that it affords us the opportunity to identify emerging trends in public health. I believe that maintaining a standard of public health and educating the public about health issues are responsibilities of both emergency physicians and our government. What are your thoughts on this?

LM: So you’ve talked about the large hospital corporations setting policies that put business before patients. You’ve talked about how they set policies that result, essentially, in poor outcomes for patients and interfere with the doctor-patient relationship. What is your position on the corporate practice of medicine? RM: Huge corporations taking over the practice of medicine is going away from one of the basic principles on which our country was founded, and that is fair competition. Large corporations have a huge advantage over individual practices and democratic group practices, and that’s antitrust and that drives prices up. My wife is an oncologist, and she told me about an instance where the cost of a B12 injection at a particular hospital system went from $12 to $150. It’s the same drug. It’s the same nurse administering the injection. It’s the same pharmacy dispensing it. But the hospital system is allowed to set separate charges for each step in the process and to drive the cost up because they have no competition. Look at what insurance companies can do with prior approval regulations. Physicians can’t automatically do what they know the patient needs. The insurance company decides what treatment they will allow the patient to have. Look at the cost of drugs like Epipen, insulin and colchicine. These prices exist because pharmaceutical corporations have a monopoly on drugs. A fair market solution in medicine is possible. It happened with Lasik. That procedure is safer and cheaper than it has ever been because there has been open competition in that marketplace. What we have now with mega-corporations buying out hospitals and hospital based medical practices is no competition at all. And the losers are the physicians and the patients. Emergency physicians aren’t self-regulating within our own organizations. Look at the proliferation of residency programs that are being accredited by the ACGME. Very soon, there are going to be too many of us, and this is just what large corporations want because then we’ll be dirt cheap to employ. And now, these corporations are putting mid-level health care professionals into positions where it

RM: I agree 100%! And there’s a lot of false information out there. This has become especially evident over the past two years as we’ve been experiencing the COVID pandemic. One of our biggest problems is that we can’t seem to separate medicine from politics. We’ve made COVID political. And that’s ridiculous. This is not a political issue. This is an issue of public health. Getting vaccinated, social distancing, and wearing a mask should be decided based on the evidence, not on the basis of political affiliation. And even within parties now, members are criticizing other members for decision making that is not along party lines, when what they should be looking at is scientific evidence. We should be leading by example, both in medicine and in government. We’ve made racism political as well. Racism is not a political problem—it’s a human problem. This is all about respect. I don’t know what your political affiliation is or what your religion is, but every major religion teaches respect for others and the value of treating others as we want to be treated. People want to be respected. They want to feel valued. Let’s break bread together and talk about it. You can’t force people to see things your way. You won’t win anyone to your side by calling them names. One thing I learned when I got my MBA is to take the emotion out of it. You can’t sell something unless you show people the value of it to them, what makes it attractive to them.

COMMON SENSE JANUARY/FEBRUARY 20221

LEGISLATORS IN THE NEWS

LM: Interesting you say that. My son got his booster a couple of days ago, and he came home and told me that what he observed at the pharmacy is that we have so demonized the anti-vaxxers that we have created an environment where those seeking information about the vaccine, who just have some questions and want some information, are afraid to ask anything for fear of being demonized and lumped in with the anti-vaxxer group. RM: Precisely. When we demonize people for holding a particular opinion rather than engaging them in respectful, logical conversation; hearing them out and listening to their point of view, we lose the opportunity to present them with medical evidence and the facts they actually need to make the right decision. We don’t explain how they will benefit from best practices. We just make them feel like we think they’re wrong. And that shuts down the dialog. LM: You’ve mentioned the politicization of COVID in the US, and you’re giving a cogent explanation of why we seem so polarized around what we as physicians know to be best practices. Many other nations have managed the COVID pandemic more effectively than the US has done. Why do you think this is, and what measures will you advocate for as an elected official to better control the spread of COVID and ensure better outcomes for those who do become infected? RM: So, yes, I definitely think the politicization of the issue has been one of our major errors. Make it a medical issue, a science issue, because that’s what it is! We’re just confusing the public and drawing their attention away from what actually matters: the science. Now, this is the novel coronavirus, and we’ve learned a whole lot since March 2020, but we still have more to learn. So, we also need to create an environment where doctors are allowed to disagree with each other. That’s part of the process of analyzing evidence and developing best practices. We don’t demonize doctors for having disagreements about antibiotics. Why can’t we have the same respect for differing opinions on COVID? If we’ve learned anything, it would be that no one has been 100% correct about anything COVID related since the beginning. Each variant will be different and we will need to learn more. A healthy environment that fosters scientific inquiry and respectful discussion of the evidence and interpretation of the evidence is what will lead us forward in defeating this pandemic.

COMMON SENSE JANUARY/FEBRUARY 2022

LM: Dr. McCormick, I want to thank you for taking the time to talk with me today and to share your perspectives with our AAEM members. You mentioned that you don’t know my political affiliations. Most of the AAEM members who’ve heard me speak know that I am a pretty far left liberal, although I vote as an independent. I enjoyed our conversations in Washington, D.C. tremendously and I really enjoyed our conversation today. I think our differing political affiliations but our closely aligned positions on the corporate practice of medicine, the importance of respectful dialog, and the need to depoliticize COVID prove a really important point. That point is that as emergency physicians, what we value most is giving the very best to every patient, providing the best value for time and money spent, and being able to practice medicine without unnecessary interference since no one knows medicine better than we do. I think the most important things that people like you will bring to Congress is exactly what makes for a great EP: being a good listener, having respect for all people no matter our differences, the ability to look at the facts without emotion, and wanting the best outcomes for everyone. We will be excited to follow your legislative career, and we hope you will join us at the Scientific Assembly in April for further discussion about the important health care issues facing the nation today.

Biography of Dr. Rich McCormick With over 20 years in the U.S. Marine Corps and Navy, Dr. McCormick served in combat zones in Africa, the Persian Gulf, and Afghanistan. As a Marine, he flew helicopters and taught at Georgia Tech and Morehouse College as the Marine Officer Instructor. In the Navy, Dr. McCormick earned the rank of Commander and served as the Department Head for the Emergency Medicine Department in Kandahar, Afghanistan. Dr. McCormick is a graduate of Morehouse School of Medicine where he was also student body president, and completed residency in emergency medicine through Emory while training at Grady Hospital in Atlanta. He also received his MBA from National University in California. Dr. McCormick and his wife, Debra, an oncologist, have seven children and live in Suwanee.

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 12-31-2021. 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 $1000 and above

Contributions $250-$499

Andrew P. Mayer, MD FAAEM Calvin C. Krom III, DO FAAEM Corey Heitz, MD FAAEM Damian Liebhardt, DO FAAEM FAWM David A. Farcy, MD FAAEM FCCM John V. Murray, MD FAAEM Kimberly Donahue, MD Lisa A. Moreno, MD MS MSCR FAAEM FIFEM Mark S. Penner, DO FAAEM Peter G. Anderson, MD FAAEM Ronald T. Genova, MD FAAEM William T. Durkin Jr., MD MBA MAAEM FAAEM

Brian R. Potts, MD MBA FAAEM Carol Pak-Teng, MD FAAEM Clifford J. Fields, DO FAAEM Dale S. Birenbaum, MD FAAEM Daniel F. Danzl, MD MAAEM FAAEM Daniel T. McDermott, DO FAAEM David W. Kelton, MD FAAEM Deborah D. Fletcher, MD FAAEM Don L. Snyder, MD FAAEM Edward A. Panacek, MD MPH FAAEM Eric S. Kenley, MD FAAEM Everett T. Fuller, MD FAAEM Frank L. Christopher, MD FAAEM Jacob Lentz, MD FAAEM Jalil A. Thurber, MD FAAEM James Webley, MD FAAEM Jeffrey A. Rey, MD FAAEM Jeffrey D. Anderson, MD FAAEM FACEP Joanne Williams, MD MAAEM FAAEM John C. Kaufman, MD FAAEM John E. Hunt III, MD FAAEM Jonathan F. Shultz, MD FAAEM Joshua J. Solano, MD FAAEM Kailyn Kahre-Sights, MD FAAEM Kathleen Hayward, MD FAAEM Kathryn Getzewich, MD FAAEM Katrina Green, MD FAAEM Kay Whalen, MBA CAE Kevin Allen, MD FAAEM Kevin S. Barlotta, MD FAAEM Kimberly M. Brown, MD MPH FAAEM Lawrence A. Melniker, MD MS MBA FAAEM Leonardo L. Alonso, DO FAAEM Lisa A. Moreno, MD MS MSCR FAAEM FIFEM Lon Kendall Young, MD FAAEM Marianne Haughey, MD FAAEM Mark A. Antonacci, MD FAAEM Michael Currie, FAAEM Michael Luszczak, DO FAAEM Michael Rosselli, MD FAAEM Michael Slater, MD FAAEM Michelle E. Clinton, MD FAAEM Neal Handly, MD FAAEM Neena Gupta, MD FAAEM Owen T. Traynor, MD FAAEM Paul C. Tripathi, MD FAAEM Ryan M. Cruz, MD FAAEM Sameer D. Mistry, MD CPE FAAEM Sarah Hemming-Meyer, DO FAAEM Scott P. Marquis, MD FAAEM Shireen Khan, MD Stewart M. Wente, MD FAAEM Tamari A. Gurevich, BSN, RN, CEN Taryn Rose

Contributions $500-$999 Albert L. Gest, DO FAAEM Alison S. Hayward, MD MPH FAAEM Bao L. Dang Bobby Kapur, MD MPH CPE FAAEM Brian J. Wieczorek, MD FAAEM Bruce E. Lohman, MD FAAEM Christine Stehman, MD FAAEM David Anthony Hnatow, MD FAAEM David Baumgartner, MD MBA FAAEM David T. Williams, DO FAAEM David W. Lawhorn, MD MAAEM FAAEM Dirk C. Schrader, MD FAAEM Edgar McPherson, MD FAAEM Eric W. Brader, MD FAAEM Ernest L. Yeh, MD FAAEM FAEMS Evan A. English, MD FAAEM Fred Earl Kency Jr., MD FAAEM FACEP Garrett Clanton II, MD FAAEM Julie A. Littwin, DO FAAEM Julie Vieth, MD FAAEM Kathleen P. Kelly, MD FAAEM Keith D. Stamler, MD FAAEM Leonard A. Yontz, MD FAAEM Marc B. Ydenberg, MD FAAEM Mark D. Thompson, MD FAAEM Mary Jane Brown, MD FAAEM Nancy Kragt, DO Oscar A. Marcilla, MD FAAEM Prasanth Boyareddigari, MD Rebecca K. Carney-Calisch, MD FAAEM Robert A. Frolichstein, MD FAAEM Robert E. Gruner, MD FAAEM Sarah Hemming-Meyer, DO FAAEM Seth Womack, MD FAAEM Stephanie Kok, MD FAAEM Ted Fan, MD FAAEM Tom Scaletta, MD MAAEM FAAEM Travis Omura, MD FAAEM Ugo E. Gallo, MD FAAEM Vicki Norton, MD FAAEM

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Contributions $100-$249 Aaron P. Montgomery, MD, ABFM Alex You, MD FAAEM Alexander D. Dzurik, MD FAAEM Alison S. Hayward, MD MPH FAAEM Analysa Gallegos, MD FAAEM Anatoliy Goltser, MD FAAEM Andy Walker, MD MAAEM Angel Feliciano, MD FAAEM Ann Loudermilk, MD FAAEM Anthony J. Callisto, MD FAAEM Barry Diner, MD, MPH, FAAEM Beau Gedrick, DO Benjamin P. Davis, MD FAAEM FACEP Bradley K. Gerberich, MD FAAEM Brandon Faza, MD MBA FAAEM FACEP Brett Bechtel, MD FAAEM Brian Kenny, DO Bruce M. Lo, MD MBA RDMS FAAEM Carol Lynn Clark, MD FAAEM Casey N. Locarnini, MD FAAEM Chad David Listrom, MD FAAEM Chaiya Laoteppitaks, MD FAAEM Charles E. Cady, MD FAAEM FAEMS Christine Coleman, MD FAAEM Christine Stehman, MD FAAEM Christopher Kang, MD FAAEM Christopher Thom, MD FAAEM D. Scott Moore, MS DO FAAEM Daniel Elliott, MD FAAEM Daniel T. McDermott, DO FAAEM David A. Halperin, MD FAAEM David Anthony Hnatow, MD FAAEM David R. Hoyer Jr., MD FAAEM David R. Steinbruner, MD FAAEM Deborah M. Fernon, DO FAAEM Derek L. Marcantel, MD FAAEM Donald J. Linder, DO FAAEM Douglas Anthony Smith, DO Edward A. Panacek, MD MPH FAAEM Elizabeth A. Fair, MD FAAEM Elizabeth Bockewitz, MD FAAEM Elizabeth Edwards, FAAEM Eric M. Ketcham, MD MBA FAAEM FASAM Ernest H. Leber Jr., MD FAAEM Evan Jackson, DO, MPH Felipe H. Grimaldo Jr., MD FAAEM Gary M. Gaddis, MD PhD FAAEM FIFEM Gary W. Fausone, FAAEM George Robert Woodward, DO FAAEM Gerald E. Maloney Jr., DO FAAEM Haley R. Davis, MD FAAEM

Heath A. Jolliff, DO FAAEM Hemali Shah, MD FAAEM Henry Zeng, MD MPH FAAEM Hillary Harper, MD FAAEM FACEP Holly A. Gardner, MD FAAEM Ian Glen Ferguson, DO FAAEM Isaac A. Odudu, MD FAAEM Isaac Philip, MD Jacob Lentz, MD FAAEM James A. Pfaff, MD FAAEM James R. Gill, MD MBA FAAEM James Webley, MD FAAEM Jane Wieler, DO FAAEM Jeffery D. Hillesland, MD FAAEM Jeffery M. Pinnow, MD FAAEM FACEP Jeffrey Gerton, FAAEM John D. Elliott, MD FAAEM Johnathon K. Lowe, DO Jon T. Beezley, DO FAAEM Jonathan D. Apfelbaum, MD FAAEM Joseph Flynn, DO FAAEM Joseph Margheim, MD FAAEM, FACEP Joseph R. Twanmoh, MD MBA FAAEM Joseph W. Hensley, DO FAAEM Joshua Tiao, MD Juan F. Acosta, DO MS FAAEM Julie A. Littwin, DO FAAEM Julie Vieth, MD FAAEM Justin P. Anderson, MD FAAEM Kari A. Lemme, MD FAAEM, FAAP Karl A. Nibbelink, MD FAAEM Katherine Ryan, MD FAAEM Kathleen Hayward, MD FAAEM Kathryn Getzewich, MD FAAEM Kathy Uy, MS CMP DES Katrina Green, MD FAAEM Katrina Landa, MD FAAEM Kevin Allen, MD FAAEM Kevin C. Reed, MD FAAEM Kevin Robert Brown, MD FAAEM Kevin S. Barlotta, MD FAAEM Kevin T. Jordan, MD FACEP FAAEM Kian J. Azimian, MD FAAEM Kimberly K. Getzinger, FAAEM Kimberly M. Brown, MD MPH FAAEM Kimberly Marie Henley, MD FAAEM Kristen A. Weibel, MBA MD Kurt E. Urban, DO FAAEM Lance H. Hoffman, MD FAAEM Larisa M. Traill, MD FAAEM Laura Ortiz, MD FAAEM Leah Houston Linda Sanders, MD FAAEM Liza Chopra, MD FAAEM Luke Buhrmester Marc D. Squillante, DO FAAEM Marco Anshien, MD

COMMON SENSE JANUARY/FEBRUARY 20221

AAEM FOUNDATION CONTRIBUTORS – THANK YOU!

Margaret R. Lewis, MD FAAEM Mark A. Newberry, DO FAAEM FACEP Mary Ann H. Trephan, MD FAAEM Matt Rutz, MD FAAEM Matthew B. Underwood, MD FAAEM Matthew C. Bombard, DO FAAEM Michael Chuang, MD FAAEM Michael S. Ritter, MD FAAEM Michelle C. Pesek-McCoy, MD FAAEM Michelle M. Walther, MD FAAEM Miguel L. Terrazas III, MD FAAEM Nicholas S. Larson, MD FAAEM Nicolette Vaghela Orlando J. Encarnacion, MD FAAEM Pamela A. Ross, MD FAAEM Patrick G. Woods, MD FAAEM Paul W. Gabriel, MD FAAEM Peter M.C. DeBlieux, MD FAAEM R. Gentry Wilkerson, MD FAAEM R. Sean Lenahan, MD FAAEM Ramon J. Pabalan, MD FAAEM Regina Hammock, DO FAAEM Richard D. Brantner, MD FAAEM Richard E. Daily, MD FAAEM Robert Boyd Tober, MD FAAEM Robert Kogel, MD FAAEM Robert P. Lam, MD FAAEM Robert R. Westermeyer II, MD FAAEM Sachin J. Shah, MD FAAEM Sam S. Torbati, MD FAAEM Sarah B. Dubbs, MD FAAEM Scott Beaudoin, MD FAAEM Scott Leuchten, DO FAAEM Scott P. Marquis, MD FAAEM Sean Lane Sean M. Abraham, DO FAAEM Seth Lotterman, MD FAAEM Shane R. Sergent, DO FAAEM Shannon M. Alwood, MD FAAEM

Shayne Gue, MD, FACEP, FAAEM Stephanie Eden, MD FAAEM Stephen P. Stewart, MD FAAEM Steve C. Christos, DO MS FACEP FAAEM Steven Parr, DO FAAEM Steven R. Shroyer, MD FAAEM Stuart M. Gaynes, MD FAAEM Sudhir Baliga, MD FAAEM Susan Socha, DO FAAEM Tara Shapiro, DO FAAEM Theodore G. Lawson, MD FAAEM Tiffany Alima, MD FAAEM Timothy J. Huschke, DO FAAEM Timothy J. Schaefer, MD FAAEM Tito Suero Salvador, MD Tomer Begaz, MD FAAEM Tracy R. Rahall, MD FAAEM Tushar R. Patel, MD MPH FAAEM Vinicius Knabben, MD Virgle O. Herrin Jr., MD FAAEM Walter M. D’Alonzo, MD FAAEM William K. Clegg, MD FAAEM Ziad N. Kazzi, MD FAAEM FACMT FAACT

Contributions up to $99 Ahmed Mahmood, MD FAAEM Alex Kaplan, MD FAAEM Alexandra Smith Alexei Adan, MD Allan Ricardo Preciado Tolano, MD Ameer Sharifzadeh, MD Andrew Edds Ann Loudermilk, MD FAAEM Benjamin Bloom, MD Benjamin P. Davis, MD FAAEM FACEP Brittany M. Molitoris Bruce Donenberg, MD FAAEM

Charles R. Phillips, MD Charles Spencer III, MD FAAEM Curtis Lee Lowery III, MD, PhD David C. Crutchfield, MD FAAEM David R. Steinbruner, MD FAAEM Dean J. Williams, MD FAAEM Devon Peele, MD FAAEM Douglas S. Lee, MD FAAEM Edward T. Grove, MD FAAEM MSPH Elizabeth A. Moy, MD FAAEM Eric J. Zoog, MD FAAEM Esteban C. Torres Freya Dittrich, DO FAAEM Garett C. Foster Gholamreza Sadeghipour Roodsari Giorgi Maziashvili Grace Foulis Heather Wood Hilary McManus Jacob Lentz, MD FAAEM Jake Gold, MD James Arnold Nichols, MD FAAEM James J. Suel, MD FAAEM James P. Alva, MD FAAEM James T. Buchanan Jr., MD FAAEM John K. Wall, MD FAAEM Jose I. Ruiz-Quinones, MD FAAEM Joseph Flynn, DO FAAEM Joseph T. McCaslin, MD FAAEM Karina Herrera Kathleen E. Cavell Kristina N. Hester, MD FAAEM Kyle Heidinger Laura Barrera Lawrence E. Isaacs, MD FAAEM Lisa A. Lyons, MD FAAEM Lisa Irwin Marc D. Squillante, DO FAAEM Maria Bernal

ED Operations Certificate Course Optimizing the management of your ED: patient flow, experience, quality, and safety

www.aaem.org/education/events/edocc 18

COMMON SENSE JANUARY/FEBRUARY 2022

Mariah G. Welka Matt Rudy, MD FAAEM Matthew Mosko Mass, DO Matthew R. Brewer, MD Melanie Bay Michael A. Cecilia, DO Michael S. Oertly, MD FAAEM Michelle C. Pesek-McCoy, MD FAAEM Michelle Feltes, MD Monisha Bindra, FAAEM Natasha Trainer Nathan J. Borden, MD FAAEM Nathanial B. Karraker Nicholas S. Larson, MD FAAEM Nikki Baldwin Orlando J. Encarnacion, MD FAAEM Pamela J. Krol, MD FAAEM Paulette Gori, MD FAAEM Richard D. Brantner, MD FAAEM Robert Bassett, DO FAAEM Robert Boyd Tober, MD FAAEM Robert E. Gruner, MD FAAEM Robert W. Bankov, MD FAAEM FACEP Ryan Horton, MD FAAEM Samantha Flynn Shireen Khan, MD Stephen J. Lowery, FAAEM Stuart M. Gaynes, MD FAAEM T. Andrew Windsor, MD RDMS FAAEM Theresa Kunkel, LPN, WSOC Thomas G. Derenne Timothy J. Durkin, DO FAAEM CAQSM Timothy P. Dotzler, DO FAAEM Tracy R. Rahall, MD FAAEM Walter M. D’Alonzo, MD FAAEM William R. Hinckley, MD CMTE FAAEM William Young, DO FAAEM Yvo Van der Hoek

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 12-31-2021.

Contributions $1000 and above

Contributions $100-$249

William T. Durkin Jr., MD MBA MAAEM FAAEM Mark S. Penner, DO FAAEM

Adria Ottoboni, MD FAAEM Alex You, MD FAAEM Andrew P. Mayer, MD FAAEM Benjamin P. Davis, MD FAAEM FACEP Brandon Faza, MD MBA FAAEM FACEP Brendon L. Gelford, MD FAAEM Brett Bechtel, MD FAAEM Brian R. Potts, MD MBA FAAEM Chaiya Laoteppitaks, MD FAAEM Christine Coleman, MD FAAEM Christopher Luttig, MD FAAEM Clifford J. Fields, DO FAAEM Cynthia Martinez-Capolino, MD FAAEM Daniel T. McDermott, DO FAAEM David A. Halperin, MD FAAEM David Baumgartner, MD MBA FAAEM David R. Hoyer Jr., MD FAAEM David R. Steinbruner, MD FAAEM David W. Kelton, MD FAAEM Deborah D. Fletcher, MD FAAEM Deborah M. Fernon, DO FAAEM Derek L. Marcantel, MD FAAEM Don L. Snyder, MD FAAEM Elizabeth Bockewitz, MD FAAEM Elizabeth Edwards, FAAEM Evan A. English, MD FAAEM Evan Jackson, DO, MPH Felipe H. Grimaldo Jr., MD FAAEM Gary W. Fausone, FAAEM Haley R. Davis, MD FAAEM Heath A. Jolliff, DO FAAEM Jalil A. Thurber, MD FAAEM James Webley, MD FAAEM Jeffrey A. Rey, MD FAAEM Jeffrey D. Anderson, MD FAAEM FACEP Jeffrey Gerton, FAAEM Jonathan F. Shultz, MD FAAEM Jordan D. Thiesen, DO FAAEM Joseph Margheim, MD FAAEM, FACEP Joseph W. Hensley, DO FAAEM Julie A. Littwin, DO FAAEM Justin P. Anderson, MD FAAEM Katrina Green, MD FAAEM Kevin Allen, MD FAAEM Kevin S. Barlotta, MD FAAEM

Contributions $500-$999 Bao L. Dang Damian Liebhardt, DO FAAEM FAWM David A. Farcy, MD FAAEM FCCM Julie Vieth, MD FAAEM Lisa A. Moreno, MD MS MSCR FAAEM FIFEM Peter G. Anderson, MD FAAEM Ronald T. Genova, MD FAAEM Seth Womack, MD FAAEM

Contributions $250-$499 Albert L. Gest, DO FAAEM Alison S. Hayward, MD MPH FAAEM Brian J. Wieczorek, MD FAAEM Bruce E. Lohman, MD FAAEM David Anthony Hnatow, MD FAAEM David T. Williams, DO FAAEM Dirk C. Schrader, MD FAAEM Edgar McPherson, MD FAAEM Eric S. Kenley, MD FAAEM Eric W. Brader, MD FAAEM Garrett Clanton II, MD FAAEM Jacob Lentz, MD FAAEM James Webley, MD FAAEM Joseph T. Bleier, MD FAAEM Julie A. Littwin, DO FAAEM Kathryn Getzewich, MD FAAEM Marianne Sacasa De Strasberg, MD FAAEM Mark D. Thompson, MD FAAEM Michael Rosselli, MD FAAEM Prasanth Boyareddigari, MD Robert A. Frolichstein, MD FAAEM Sameer D. Mistry, MD CPE FAAEM Sarah Hemming-Meyer, DO FAAEM Scott P. Marquis, MD FAAEM Shireen Khan, MD Stewart M. Wente, MD FAAEM Ugo E. Gallo, MD FAAEM Vicki Norton, MD FAAEM

Kimberly K. Getzinger, FAAEM Kimberly M. Brown, MD MPH FAAEM Kristen A. Weibel, MBA MD Kurt E. Urban, DO FAAEM Larisa M. Traill, MD FAAEM Lawrence A. Melniker, MD MS MBA FAAEM Leah Houston Leonardo L. Alonso, DO FAAEM Linda Sanders, MD FAAEM Liza Chopra, MD FAAEM Marc B. Ydenberg, MD FAAEM Marc D. Squillante, DO FAAEM Marco Anshien, MD Margaret R. Lewis, MD FAAEM Marianne Haughey, MD FAAEM Mark A. Antonacci, MD FAAEM Mark A. Newberry, DO FAAEM FACEP Mark O. Simon, MD FAAEM Matthew B. Underwood, MD FAAEM Matthew C. Bombard, DO FAAEM Michelle C. Pesek-McCoy, MD FAAEM Michelle E. Clinton, MD FAAEM Miguel L. Terrazas III, MD FAAEM Nicholas S. Larson, MD FAAEM Orlando J. Encarnacion, MD FAAEM Owen T. Traynor, MD FAAEM Paul W. Gabriel, MD FAAEM Peter M.C. DeBlieux, MD FAAEM R. Gentry Wilkerson, MD FAAEM Rebecca K. Carney-Calisch, MD FAAEM Robert Boyd Tober, MD FAAEM Robert P. Lam, MD FAAEM Sachin J. Shah, MD FAAEM Sam S. Torbati, MD FAAEM Scott Beaudoin, MD FAAEM Sean M. Abraham, DO FAAEM Shane R. Sergent, DO FAAEM Stefan Jensen Steven Parr, DO FAAEM Teresa M. Ross, MD FAAEM Tiffany Alima, MD FAAEM Timothy J. Schaefer, MD FAAEM Tomer Begaz, MD FAAEM Tracy R. Rahall, MD FAAEM Travis Omura, MD FAAEM

Vinicius Knabben, MD William K. Clegg, MD FAAEM

Contributions up to $99 Ahmed Mahmood, MD FAAEM Alexei Adan, MD Ameer Sharifzadeh, MD Ann Loudermilk, MD FAAEM Benjamin Bloom, MD Charles Spencer III, MD FAAEM Curtis Lee Lowery III, MD, PhD Eric J. Zoog, MD FAAEM Ernest H. Leber Jr., MD FAAEM Gholamreza Sadeghipour Roodsari Hilary McManus Jake Gold, MD James J. Suel, MD FAAEM Jose I. Ruiz-Quinones, MD FAAEM Katrina Landa, MD FAAEM Kevin Robert Brown, MD FAAEM Laura Barrera Lauren Murphy, MD FAAEM Lisa A. Lyons, MD FAAEM Matthew Mosko Mass, DO Matthew R. Brewer, MD Michael A. Cecilia, DO Michael S. Oertly, MD FAAEM Michael Slater, MD FAAEM Natasha Trainer Paulette Gori, MD FAAEM Ramon J. Pabalan, MD FAAEM Robert Bassett, DO FAAEM Robert E. Gruner, MD FAAEM Ryan Horton, MD FAAEM Scott Wiesenborn, MD FAAEM Stephen J. Lowery, FAAEM Stuart M. Gaynes, MD FAAEM Timothy J. Durkin, DO FAAEM CAQSM Timothy P. Dotzler, DO FAAEM Walter M. D’Alonzo, MD FAAEM Ziyad Khesbak, MD FAAEM

COMMON SENSE JANUARY/FEBRUARY 20221

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. LEAD-EM would like to thank the individuals below who contributed from 1-1-2021 to 12-31-2021.

Contributions $500-$999 Bobby Kapur, MD MPH CPE FAAEM David A. Farcy, MD FAAEM FCCM Lisa A. Moreno, MD MS MSCR FAAEM FIFEM Peter G. Anderson, MD FAAEM Ronald T. Genova, MD FAAEM Sarah Hemming-Meyer, DO FAAEM Tom Scaletta, MD MAAEM FAAEM

Contributions $250-$499 Albert L. Gest, DO FAAEM Andrew P. Mayer, MD FAAEM Carol Pak-Teng, MD FAAEM Casey Brock Patrick, MD FAAEM FAEMS Christine Stehman, MD FAAEM Dale S. Birenbaum, MD FAAEM Daniel F. Danzl, MD MAAEM FAAEM David Anthony Hnatow, MD FAAEM David W. Lawhorn, MD MAAEM FAAEM Eric W. Brader, MD FAAEM Frank L. Christopher, MD FAAEM Fred Earl Kency Jr., MD FAAEM FACEP Kailyn Kahre-Sights, MD FAAEM Kathleen Hayward, MD FAAEM Katrina Green, MD FAAEM Kay Whalen, MBA CAE Keith D. Stamler, MD FAAEM

Leonard A. Yontz, MD FAAEM Mark D. Thompson, MD FAAEM Mary Jane Brown, MD FAAEM Oscar A. Marcilla, MD FAAEM Robert A. Frolichstein, MD FAAEM Robert E. Gruner, MD FAAEM Timothy J. Schaefer, MD FAAEM

Contributions $100-$249 Alison S. Hayward, MD MPH FAAEM Andy Walker, MD MAAEM Ann Loudermilk, MD FAAEM Brian J. Wieczorek, MD FAAEM Brian R. Potts, MD MBA FAAEM Bruce M. Lo, MD MBA RDMS FAAEM Christopher Kang, MD FAAEM Daniel Elliott, MD FAAEM David Baumgartner, MD MBA FAAEM David P. Mason, MD FAAEM FACEP David W. Kelton, MD FAAEM Edward A. Panacek, MD MPH FAAEM Eric M. Ketcham, MD MBA FAAEM FASAM Evan A. English, MD FAAEM George Robert Woodward, DO FAAEM Gerald E. Maloney Jr., DO FAAEM Hemali Shah, MD FAAEM Howard E. Jarvis III, MD FAAEM

John C. Kaufman, MD FAAEM Julie Vieth, MD FAAEM Kari A. Lemme, MD FAAEM, FAAP Kathy Uy, MS CMP DES Kevin T. Jordan, MD FACEP FAAEM Kian J. Azimian, MD FAAEM Kimberly Marie Henley, MD FAAEM Laura Ortiz, MD FAAEM Lawrence A. Melniker, MD MS MBA FAAEM Lee D. Raube, DO FAAEM Marc B. Ydenberg, MD FAAEM Mark A. Antonacci, MD FAAEM Matt Rutz, MD FAAEM Michelle E. Clinton, MD FAAEM Owen T. Traynor, MD FAAEM Rebecca K. Carney-Calisch, MD FAAEM Regina Hammock, DO FAAEM Robert P. Lam, MD FAAEM Sarah B. Dubbs, MD FAAEM Stuart M. Gaynes, MD FAAEM Sudhir Baliga, MD FAAEM Tracy R. Rahall, MD FAAEM Travis Omura, MD FAAEM Tyler M. Stepsis, MD FAAEM Ugo E. Gallo, MD FAAEM Vicki Norton, MD FAAEM

Contributions up to $99 Benjamin P. Davis, MD FAAEM FACEP Charles R. Phillips, MD David R. Steinbruner, MD FAAEM Douglas S. Lee, MD FAAEM Edward T. Grove, MD FAAEM MSPH Grace Foulis Jacob Lentz, MD FAAEM Joel Mosley, MD FAAEM John K. Wall, MD FAAEM Joseph Flynn, DO FAAEM Kevin Robert Brown, MD FAAEM Lawrence E. Isaacs, MD FAAEM Marc D. Squillante, DO FAAEM Michael Slater, MD FAAEM Pamela J. Krol, MD FAAEM Ramon J. Pabalan, MD FAAEM Richard D. Brantner, MD FAAEM Robert Bassett, DO FAAEM Robert Boyd Tober, MD FAAEM Robert W. Bankov, MD FAAEM FACEP Seth Lotterman, MD FAAEM Theodore M. Willmore, MD FAAEM Thomas G. Derenne Virgle O. Herrin Jr., MD FAAEM

AAEM Member Acknowledgements Lisa A. Moreno, MD MS MSCR FAAEM FIFEM INDUSEM Award – WACEM Leader of the Year The recipient of this honor is an academician who has made a niche by conducting research and education across the world thus fostering and growing emergency medicine at the international level. INDUSEM awards are bestowed on eminent people who have done extraordinary work in their fields. Dr. Moreno received this award for advancing global emergency medicine, academic education, and innovation research with a focus on diversity, equity, and inclusion. If you or an AAEM member you know has received an award or special recognition and would like it acknowledged here, please contact cseditor@aaem.org.

COMMON SENSE JANUARY/FEBRUARY 2022

L A R G E C A R T- B E N C H M A R K E D I M A G I N G A I – C O R E L A B V A L I D AT E D A L G O R I T H M S * A V A L U E G R E AT E R T H A N Y O U ’ D E X P E C T

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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/events

AAEM Events

Recommended

April 23-27, 2022 AAEM’s 28th Annual Scientific Assembly (Baltimore, MD) https://www.aaem.org/aaem22

March 11-13, 2022 2022 ACMT Annual Scientific Meeting (San Antonio, TX) https://www.acmt.net/cgi/page.cgi/Annual_Scientific_Meeting.html

21-24 September 2022 XIth Mediterranean Emergency Medicine Congress (St. Julian, Malta) https://www.aaem.org/memc21

March 18-20, 2022 The Difficult Airway Course: EmergencyTM (New Orleans, LA) www.theairwaysite.com

Jointly Provided

March 31-April 2, 2022 ASRA Regional Anesthesiology and Acute Pain Medicine Meeting (Las Vegas, NV) https://www.asra.com/events-education/ra-acute-meeting

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

April 8-10, 2022 The Difficult Airway Course: EmergencyTM (Boston, MA) www.theairwaysite.com

March 9, 2022 Delaware Valley Chater Division Annual Residents’ Day (Virtual) – Jointly provided by DVAAEM https://www.aaem.org/get-involved/chapter-divisions/dvaaem/ residents-day-and-meeting

April 23, 2022 Advances in Cancer ImmunotherapyTM: Immune Checkpoint Inhibitors (Virtual) https://www.sitcancer.org/education/aci/2021-2022/ immunecheckpointinhibitors

July 27-29, 2022 Coalition for Physician Well-Being 10th Annual Conference (Denver, CO)

April 28, 2022 Advances in Cancer ImmunotherapyTM: A Focus on Toxicity Management (Houston, TX and Virtual) https://www.sitcancer.org/education/aci/2021-2022/toxicityirae

https://www.forphysicianwellbeing.org/

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FINANCIAL WELLNESS: A 5-PART SERIES ON MANAGING MONEY WISELY

Financial Planning: An Important Part of Beating Burnout James M. Dahle, MD FAAEM FACEP

ur medical education has taught us many things that we put to use every day. Unfortunately, financial literacy is usually not one of them. While physicians are high earners, many of us often don’t know the first thing about how to save, invest, and spend money wisely. The stresses of financial instability significantly impact our personal well-being. In order to help fill this knowledge gap, the Wellness Committee has invited Dr. James Dahle, founder of The White Coat Investor and fellow EM physician, to contribute a series of five Common Sense articles to address critical topics on financial wellbeing. Burnout has reached epidemic proportions, with some surveys showing over 50% of doctors are currently experiencing burnout symptoms. For many of those, burnout is having a severe effect on their personal and professional lives. While not exclusive to physicians, the unique stresses of health care have certainly kept doctors among the most burned out of professions. Surveys of the various specialties show that emergency physicians continue to rank near the top as a percentage of practitioners affected. The symptoms and causes of burnout are well-described elsewhere, but it is clear from years of research that causes are both systemic and personal, and thus the best solutions will address both aspects. Systemic solutions are more difficult to implement, but may be much more effective. Every physician should lend their support to systemic change and solutions



The largest financial asset of most physicians, particularly in the early career, is their ability to work.” to improve the profession and individual organizations where ever possible. However, in this article we are going to address just one alleviating factor for burnout—financial planning. The good news is that this solution can be implemented immediately and without support from any organization or any co-worker. The largest financial asset of most physicians, particularly in the early career, is their ability to work. That is, to exchange their time and effort for money at a relatively high rate. Most emergency physicians earn between $150 and $400 per hour. Over a full career, those earnings may add up to over $10 million. This asset needs to be protected. While most of us are aware of the need for disability and life insurance to protect this asset, few of us consider that burnout also puts it at risk. In fact, given its prevalence, a given emergency physician is far more likely to leave medicine early due to burnout than disability or death. Burnout is your greatest financial risk. Thus, all career decisions should be made with this risk in mind. You should ask yourself, “Will this decision make me more or less likely to burn out early?” Optimizing for career longevity is clearly the number one priority. That might mean working fewer shifts, leaving a toxic job, paying someone else to work your share of night shifts, or simply accepting the lower compensation that often comes with seeing fewer

patients per hour as an individual or even as a group. Financial planning is the process of aligning your working time and earned dollars with your personal values and goals. It involves setting goals, deciding how much money to dedicate to each of those goals, persistently investing money toward each of those goals in an intelligent manner, and protecting the assets you do have from loss. It is a single player game, you against your goals, and you do not need to beat your friends or even the market in order to reach your own financial goals. Doctors with clear financial goals and a written plan to meet them are far less likely to burn out, and should they do so, they are already in a financial position that allows them to do something about it. I am convinced that financially secure doctors are better partners, parents, and practitioners. Many doctors feel trapped in medicine. This trap often starts in medical school as they begin to accumulate student loans. Approximately three-fourth of graduating students paid for school using borrowed money, with a median amount at graduation currently between $200,000 and $300,000. However, many doctors owe even more and a $400,000 or even $500,000 student loan burden is no longer unusual. If managed poorly, those debts may still be hanging over their head during late career. Even once that student loan mess has

>> COMMON SENSE JANUARY/FEBRUARY 20221

FINANCIAL WELLNESS: A 5-PART SERIES ON MANAGING MONEY WISELY

been cleaned up, every dollar of that relatively high physician income may be required to maintain the lifestyle and spending habits of physicians and their families. Poor investing habits and personal financial catastrophes such as divorce may compound the problem and by the time they get into their 60s, 25% of doctors are still not millionaires, despite decades of physician-level earnings. In fact, 11-12% of doctors in their 60s still have a net worth (everything you own minus everything you owe) of under $500,000. Needless to say, a nest egg of that size will not provide anywhere near the same lifestyle in retirement that the physician enjoyed prior to retirement. The main outcome of the financial planning process is a written financial plan. Once this plan is produced, the physician investor no longer needs to think about the answers to questions such as: • • • •

How much can I spend? Can I afford to buy X, Y, or Z? How much should I be saving for retirement and college? Should I put this extra money toward the mortgage or invest it?



By getting your financial ducks in a row, you will be empowered with the ability to make changes in your personal and professional life to ensure career longevity.” The plan answers all of those questions and simply needs to be followed. It is personalized and comprehensive. Most physicians will require the assistance of a professional financial planner to draft such a plan. Expect to pay several thousand dollars to do so, and that much every year if you also hire the planner to implement the plan. Just be careful that you are not hiring a financial product salesman masquerading as a financial planner. The easy way to tell the difference is by understanding how they are paid. If they are paid commissions to sell you insurance or investments, they are not a financial planner, they are an agent. If they are paid a percentage of your assets, they are an asset manager, not a financial planner. That is not to say one cannot be both, but as a general rule you will find people put the most effort into doing what they are actually paid to do.

COMMON SENSE JANUARY/FEBRUARY 2022

If you wish to draft your own financial plan, you will find the task is not too overwhelming. Many physicians act as their own financial planner and investment manager after becoming financially literate. The process takes some time and effort, but far less than it took to practice medicine. There are plenty of inexpensive resources to assist you including blogs, podcasts, books, online communities, and courses. The key is that if you decide to do it yourself, you must make sure it is done well. You would be far better off paying a fair price for good advice and service than doing a lousy job yourself. With a financial plan in place, you will find that you rapidly begin to gain wealth by paying off debt, accumulating assets, and letting the magic of compound interest work on those assets over time. By getting your financial ducks in a row, you will be empowered with the ability to make changes in your personal and professional life to ensure career longevity. These may include: • • • • • • • • •

Cutting back at work Taking more vacation Having more time to spend with friends and family Having more time to spend on wellness boosting activities such as exercise, eating well, and sleeping Working a different mix of shifts Changing jobs Changing professions Forcing change at your current job Chasing academic pursuits that do not necessarily compensate well

Most emergency physicians following a simple financial plan will reach financial independence by mid to late career. At that point, they no longer need to work for money at all. While some will retire early to pursue other interests, many will discover that they really did not go into medicine for the money and find it is far more enjoyable now that they no longer have to do it. James M. Dahle, MD FAAEM FACEP is a practicing emergency physician and the founder of The White Coat Investor, the most widely-read physician specific financial website in the world, a best-selling author, and a popular podcaster.1

References 1. https://www.whitecoatinvestor.com/

The Parking Lot: End-of-Life Conversations in the Era of COVID-19

HEART OF A DOCTOR

Pavitra Parimala Krishnamani, MD MS

“S

he was just up, walking, and jovial last week, doctor,” Shauna told me less than an hour after I placed a central venous catheter into a large vein in her mother’s neck. Just shy of fifty years old, her mother, Jameela Carter, had discovered far too late that she had endometrial cancer.

“She has a bowel perforation,” he said, “We’re talking about whether we can offer surgery given how high risk a patient she is and the prognosis of her cancer. It’s not looking like we’re going to go in though, just a heads up.” I nodded, scanning through her labs and noting to myself that she would be at a higher risk of bleeding during her central line placement.

By the time I met Jameela in the emergency department (ED), her cancer had made its home in every recess of her abdomen, traveling as far as her lungs, breasts, and possibly even her brain. A good majority of patients with her brand and degree of metastatic endometrial cancer had less than five years left to live. Having just discovered her cancer a month prior to meeting me, she was at a doctor’s appointment to follow

“I’ll keep that in mind,” I said, “Any idea if her family is going to be able to come over to the ED?” “Yeah, I’ll talk to them as well about our thoughts on the surgery and ask them to come in so you can speak with them in person.” “Thanks!” I said. We readied ourselves to do the procedure, laid Jameela back, monitored her breathing, and placed the line as quickly and precisely as possible. When we sat her back up, we saw that she was struggling to ventilate effectively and placed her on a BiPAP machine. We checked on her breathing often, hoping she’d improve with the least support possible. We knew that if she didn’t, she’d need an intubation and ventilatory support. For someone as sick as Jameela, we knew being on a ventilator may be permanent rather than temporary. Intubation was a last resort for Jameela. Though it may help her breathe better, it could also mean she may never speak with her family again.

Instead, we had a dark parking lot with puddles of water on the ground reflecting an ominous glow from the red sign reading ‘Emergency Department.”

We were determined to avoid that eventuality for as long as we possibly could. With a hole in her bowel and a terrible infection, Jameela deserved a few moments with her family. I breathed a sigh of relief when her breathing improved on BiPAP before my friend on the surgery service stepped into the room again to let me know that Shauna was on her way to the ED.

up on her condition when staff found her blood pressure to be low. Really low. Her systolic blood pressure was in the 50s and she was sent to the ED because her clinic was concerned that she was not perfusing appropriately.

“I spoke with her daughter,” he said, “we’re not offering the surgery but they still want us to do everything necessary to keep Ms. Carter alive.”

Although her blood pressure stabilized in the ED, it was still soft after we started her on intravenous fluids. The possibility of Jameela being in septic shock was at the forefront of our minds as we tried to tease out the exact cause of her hypotension. After a quick CT scan, Jameela’s blood pressure remained low and showed no signs of improving. Once we got her back to her room, she became increasingly tired and confused. We started her on pressors and I prepared to place a central line as my colleague contacted Shauna to get consent for the procedure. As I was getting ready to place the central line, a friend from the surgery service found me.

“Even if it means intubation?” I asked, fully aware than Jameela’s mild improvement in response to BiPAP didn’t exclude her from an intubation in the near future. “Yup, full code,” he said, referring to the fact that her family wanted Jameela to have chest compressions and ventilator-support if her heart or lungs stopped working appropriately. “Okay,” I said, “Full code it is.” Jameela’s blood pressure started dropping again. Her nurses came in, increasing her blood pressure medication as necessary to keep Jameela’s blood pressure high enough to get oxygen to the rest of her body. The speed at which we needed to increase her medication surprised us all. After an hour of monitoring, her blood pressure stabilized. And Shauna was waiting outside of the emergency department.

COMMON SENSE JANUARY/FEBRUARY 20221

HEART OF A DOCTOR

“Y’all got this?” I asked the nursing team in the room, since Jameela’s vital signs had been stabilized. “Yeah, Pavitra, go ahead and update the family.” “Thanks,” I stepped out of the room and walked through the waiting room, filled with sick patients—some were coughing, some were sleeping while they waited to be roomed in the medical core of the ED. I walked past our triage nurses working diligently to talk with every patient who had walked into the ED. I walked past security. And, finally, I walked right into the parking lot of the emergency department where I first met Shauna. It was dark outside, Shauna and her family pastor stood near a white car. Shauna stepped out of the driver’s seat when she saw me walk out of the ED, a worried expression on her face. I peeled the large industrial-grade respirator that protected me from COVID off of my face, smiling briefly in greeting before switching it out for a surgical mask instead. Shauna, I felt, deserved to catch a glimpse of the face that belonged to the doctor taking care of her sick mother. “Hi, I’m Dr. Pavitra,” I introduced myself, my feet sore from spending the majority of my shift standing with Jameela while we examined, scanned, and stabilized her. I wished desperately we could sit down and have this conversation — this conversation about whether or not Jameela would make it through a hospital stay, what her cancer meant for her even if she did survive her current condition, and how Jameela would have wanted to spend the end of her life.

“Thank god,” Shauna sighed in relief. My breath caught in my throat. Relaying bad news was never easy, but there was usually a quiet and calm room to sit in, sometimes a few bottles of water, always a box of tissues. Today, it was me, Shauna, her family’s pastor, and our masks. “I wish we weren’t having this conversation out here in the parking lot,” I started hesitantly, looking around us before resigning myself to the fact that we didn’t have another space where we could have this discussion. “Can you tell me a little bit about what information you’ve heard about your mom’s condition?” “Well, she has cancer in her uterus,” Shauna started, “we just found out five weeks ago, it was all very sudden. And, today, she just drastically got worse all of a sudden, I don’t even know how it happened. She was just up, walking, and jovial until last week, doctor.” I noticed a silver car pulling up in my periphery and instinctively shifted the three of us further away from the main doors to give us some privacy. “I understand,” I said, “Unfortunately, patients with the type of cancer your mom has can become very sick and it’s not always predictable how quickly that can happen.” “The surgeon said it was real bad, like in her breast too,” Shauna relayed.

Do you believe in miracles, doctor?’ the family’s pastor asked. ‘Absolutely,’ I sai d.”

In the height of the COVID-19 pandemic, that was a luxury we did not have. Instead, we had a dark parking lot with puddles of water on the ground reflecting an ominous glow from the red sign reading “Emergency Department” that hung above me like a caption describing the last location in which Shauna’s mother would want to be. “How’s my mother,” Shauna asked. “Right now, she’s hanging in there. We’re working on supporting her blood pressure and breathing at this moment...and we’re trying to get her to an intensive care unit (ICU), where a team of critical care doctors can take care of her.”

“Unfortunately, yes, it goes beyond her breast and is in her lungs and other parts of her body as well.” “Her lungs?” Shauna asked. This was new information for her to grapple with.

A man opened the silver car’s door. “I got shot!,” he called out. I looked over at him. He was wildly waving his arms and his legs as he looked around, “Ma’am, I got shot!” I glanced back at Shauna before turning my attention to the man. “Sir, we’ll get someone to help you immediately, just do me a favor and go inside — they can get you to a room,” I turned back to Shauna, but before I could continue our conversation, the man grew frustrated. “Whatchu talkin’ ‘bout b****, I got f***ing shot in the leg and you’re tellin’ me to go inside, I got shot in the f***ing leg and she be like ‘GOOO inside,’” he yelled. I looked back over at him and noticed a slight darkening of his sweatpants over his right leg, though it was hard to make out whether it was blood under the dim lighting.

COMMON SENSE JANUARY/FEBRUARY 2022

HEART OF A DOCTOR

“There’s no need for language like that!” the pastor spoke up.

“Do you believe in miracles, doctor?” the family’s pastor asked.

“It’s alright,” I said softly, positioning Shauna and the pastor further away from the car and placing myself between them and the man inside the vehicle, “Just give me one moment please.” Right as I was about to call for help, a security officer walked out.

“Absolutely,” I said, without missing a beat, “I’ve seen miracles and I do believe in them, but I’d be doing you all and Ms. Carter a disservice if I didn’t discuss the medical information I know with you today because the decisions you’re going to be asked to make are going to be medical decisions for Ms. Carter.”

“We’re going to get you a stretcher, man, and get you to the back alright?” he said. “Geeeez, alright, I got shot,” the man in the car muttered. I thanked the security officer before turning back to Shauna. “I’m sorry about that,” I apologized before resuming our conversation. “Yes, unfortunately your mother’s cancer is spread all over, including in her lungs.” “I see,” Shauna said, tearing up. I held her hand, noting I had sanitized my own hands right before stepping out of the department. “When my patients are this sick, I always encourage their loved ones to think about what they would have wanted for themselves, especially when it comes to how they would have wanted to live and how they would have wanted to go when it’s their time to go,” I started once Shauna had taken a moment to process the news about her mother’s cancer. “Is it her time to go now? Does she look that bad?” Shauna tensed up. “No, not right this moment, but she does look quite sick at this time. I want to make sure that during her hospitalization you’re not getting any calls at two o’clock in the morning asking you to make life and death decisions about Ms. Carter when you haven’t had a chance to think about what she may have wanted for herself. That’s why I bring this up now,” I said. “Ah, I see,” Shauna said. “And, even if she does make it through this hospitalization, it’s still important to consider what she would have wanted for herself because of how advanced her cancer is. Unless you or she tells us otherwise, we will do everything in our power to keep her alive— whether that means doing CPR if her heart stops or placing a tube down her throat to help her breathe even when she may never be able to have the tube taken out in the future.” “Okay,” Shauna paused, “Do we need to do any of that now?” “No, but earlier in the night your mom gave me a bit of a scare and we thought she may need a breathing tube placed for help. Luckily, she recovered without us having to do that, but a lot of my hesitancy came from whether or not she would have wanted that for herself. Of course, you all know her better, which is why I ask you to think about what she would have wanted.”

Shauna paused for a moment in thought before speaking again. “Everything doctor,” she finally said softly, “Do everything.” I nodded by head. “Okay, I said, I’ll pass that information along to the critical care doctors who will be taking care of her then,” I reassured her. “You all do everything you can do and we’ll keep praying for a miracle and let the Lord do what he can do as well,” the pastor said as Shauna nodded, feeling the power in her pastor’s words. “Yes, absolutely,” Shauna agreed, “Is there any way I can see her?” I looked at Shauna, wishing I could unequivocally say ‘yes.’ I wanted so desperately to take her to her mother’s bedside, pull up some chairs, and ask her and the pastor to sit by Jameela’s side and talk with her. I wanted to be able to tell them they could visit to their heart’s content and hold Jameela’s hands for as long as they wished to. Yet, in the height of a pandemic that remains unprecendented in many of our lifetimes, I was powerless to do so. Like most hospitals in this time, ours appropriately developed a strict no-visitor policy to keep our patients and the community safe. Sometimes, we made exceptions made for patients’ who were actively dying or who had died. Jameela, I decided, fell into the former category: bad infection, worse cancer. Jameela, I knew, may never walk out of the hospital once she was moved to the ICU. Shauna may not have a day to sit by her side and hold her hand, but if she could have at least five minutes to see her mother again while she was alive and talking, I knew that I couldn’t be the person to deny her those precious moments. “Okay,” I said. With a nurse’s help, we gave Shauna five minutes with her mother before walking her back outside and moving Jameela to the ICU, where she’d spend the rest of her hospital stay. Wheeling her into the elevator, I watched as the heavy chrome doors shut between her and our emergency department. I hoped that, against all odds, she’d be a miracle who makes it out of the hospital and has the chance to spend some more time up, walking, and jovial with her family before it would be her time to go.

COMMON SENSE JANUARY/FEBRUARY 20221

AAEM NEWS

Recent Corporate Practice of Medicine Case Jonathan S. Jones, MD FAAEM FACEP — President-Elect, AAEM

AEM has consistently fought against the Corporate Practice of Medicine (CPOM) as we feel that this is unsafe for patients. Many, but not all, states have laws banning the CPOM but there is no federal CPOM law. The basis of the laws banning CPOM is that the practice of medicine requires a medical license and lay corporations do not have a license. The concern, which AAEM shares, is that lay corporations have conflicts of interest in providing the best possible patient care. Lay corporations can put tremendous pressure on the ir employed or contracted physicians and force them to practice medicine contrary to the physician’s best judgment. The below case from Kansas is refreshing as it clearly upholds the state’s CPOM law. While it does not involve emergency medicine, the outcome is important and may provide insight for future action. While I am neither a lawyer nor legal scholar, I have attempted to provide a brief summary of the case with commentary on its relevance to us.

Clinical Colleagues Inc. (CCI) v. Hutchinson Regional Medical Center Inc. (HRMC) United States District Court for the District of Kansas Case No. 20-2297-JWB September 24, 2021 CCI is a corporation which provides anesthesia services and was providing them to HRMC. The hospital, HRMC, effectively fired the corporation (CCI). However, the hospital decided to retain some of the anesthesiologists so CCI sued for breach of contract. HRMC asked for dismissal by claiming that CCI was engaged in the CPOM which is disallowed in Kansas. CCI argued that the entire CPOM law violates either the US or Kansas Constitution but the court upheld the CPOM law and dismissed the case.

I hope that highlighting this case will help us realize that we in emergency medicine have natural allies in many of our fights.”

The vast majority of the twelve page decision is an explanation of why the Kansas prohibition on the CPOM is legal and constitutional. Despite several different objections raised, the court refuted each with multiple references and explanations. One specific objection raised to the CPOM law is that it serves only to protect the licensed physicians and so is basically anticompetitive. Discussion is then made that the CPOM law may further the state’s interest in the health of its citizens. The court cited further cases and made further arguments that even if the only purpose for the CPOM law is to protect the interests of physicians, it is still constitutional as states have the authority to do this. Unfortunately, there is no federal CPOM law and many states do not have CPOM laws. Also, this case only applies to Kansas and courts in other jurisdictions could come to different conclusions on the constitutionalism of CPOM laws. However, it is still an important “win” for CPOM laws. Finally, I hope that highlighting this case will help us realize that we in emergency medicine have natural allies in many of our fights. The scourge of lay corporations not only affects EM, but, as in this case, anesthesia, and now many other specialties including hospital medicine. In order to have the greatest impact, we as the Academy or as individuals must continue to coordinate and collaborate with other specialties on this and most other issues.

COMMON SENSE JANUARY/FEBRUARY 2022

AAEM NEWS

An Interview with US Congressional Candidate Sam Alexander, MD Andrew Mayer, MD FAAEM

ommon Sense has started a series of interviews of political figures. Political activism and advocacy for issues concerning emergency medicine is very important to AAEM. Our president, Dr. Lisa Moreno has previously interviewed Dr. Mark Green who is an emergency physician and a Republican Congressman from Tennessee, Dr. Amish Shah who is an emergency physician and a Democratic member of the Arizona House of Representatives, and Representative Troy Carter who is a Democratic Congressman from Louisiana. In this issue of Common Sense, we will interview a candidate for Congress. Dr. Sam Alexander is an emergency physician from Missouri and a long-time AAEM member. This is his first run for public office and AAEM would like to highlight our members’ political activism and efforts to improve our specialty. Common Sense would like to focus on his ideas related to health care and the specialty of emergency medicine. AM: Sam, can you tell us a little about yourself and how your campaign is going? SA: I have been a member of AAEM since its beginning. I work at Cox Medical Centers in Springfield, Missouri for greater than 30 years. We are one of the busiest emergency departments in the state of Missouri. Our physician group is known as the Emergency Physicians of Springfield and is one of the oldest independent democratic groups in the nation, with its founding in the 1970s. To maintain our independence, we joined the Ferrell-Duncan Clinic several years ago. Early on in my practice of emergency medicine, I saw the emergence of corporate entities that were placing non-EM board certified physicians in our emergency departments across our state. I opposed this practice from its onset. When I heard of the formation of AAEM I joined immediately and have been a staunch supporter since. Our mission and vision

statements are spot on, helping members deliver the best care for our patients. I have always been politically active and have served on the Missouri Board of Healing Arts and am currently on the Missouri Healthnet (Medicaid) oversight Committee. I personally advocate to our state Representatives, Senators, and Governors to forward the goals of AAEM. I started campaigning for Missouri’s open 7th US congressional seat five months ago. I will be a direct voice and champion for all the goals & principals of AAEM in Washington D.C. I believe strongly in our academy.

As a group of emergency department physicians, we can solve the problems of our profession—we solve problems in our practices daily.”

I am reaching out to all AAEM members to ask for financial support because I cannot win without your support. This congressional seat is solidly Republican controlled and I am running on that ticket. However, I will work for our goals in a bipartisan manner. Donations can be sent to: Dr. Sam Alexander for US Congress PO Box 10285 Springfield, MO 65808 Or donate online at www.drsamforcongress. com Any financial support would be greatly appreciated. AM: Sam, thanks for taking the time to share some of your thoughts with fellow members of AAEM. I think most of us would never consider such a bold move as to run for Congress. What motivated you at this stage of your career to run for Congress? SA: I have been active in politics all my adult life. I am truly blessed to have been involved in a physician owned and democratic practice of emergency medicine for 35 years. I have

served on multiple boards in the state of Missouri and currently serve on the Missouri Health-Net (Medicaid) Oversight Committee. So many of the decisions that affect us in our practice of emergency medicine are made at the federal level. I want to take AAEM’s principles to Washington, D.C. and enact changes that will positively improve our ability to practice emergency medicine and improve the care that we render to our patients. In each of our lives, throughout our careers we need to give and pay back to improve our profession. When elected to this office I can give back to our profession and our patients, who are being seen in the emergency department due to their social or financial ability to get medical care elsewhere. AM: Having physicians as elected officials in state or federal positions can bring significant insight into the often divisive and complex discussion of health care. If elected, what insights could you share with fellow members of Congress to help guide future decisions related to the American health care system? SA: The insight I can offer to fellow members of Congress will come from the 35 plus years of working in one of the busiest emergency

COMMON SENSE JANUARY/FEBRUARY 20221

AN INTERVIEW WITH US CONGRESS CANDIDATE SAM ALEXANDER, MD

departments in the state of Missouri. The 200,000 plus patients that I have seen and provided care for over my career are paramount for my goals of improving emergency medical care in this country. I have been a member of AAEM since its beginning. I will reach out to other members of Congress to share our academy’s guiding principles to further improve our practices for the care of our patients. I will work toward the goal of 100% board certification of our profession. I will fight to uphold physician autonomy in the practice of emergency medicine.

advance and support any issues and solutions brought to me by AAEM. I will be your voice in Washington, D.C. As a group of emergency department physicians, we can solve the problems of our profession—we solve problems in our practices daily. I would also work to improve Medicare/Medicaid reimbursements by revamping fee schedules at CMS.

AM: Emergency medicine is under attack on many fronts and our future as a specialty can at times seem uncertain. What issues would you focus on specifically related to our specialty during your first term?

SA: As a member of a physician owned, democratic group I have always had due process rights. However, approximately 30% of emergency department physicians do not have this right. I will work hard to revive and push for passage of the due process protection law, HR 6910. This is essential to protect our emergency department physicians and our patients that we serve.

SA: I will start work immediately to enact and submit legislation that will champion the principles of AAEM. I will work to revise and

AM: AAEM has been a strong advocate for Congress passing due process rights for emergency physicians. What are your thoughts concerning this issue?

I want to take AAEM’s principles to Washington, D.C. and enact changes that will positively improve our ability to practice emergency medicine and improve the care that we render to our patients.” push through HR6910 (due process) and HR 1667 (behavioral health for physicians). I will also address non-compete clauses. I will investigate ways to promote balanced growth in emergency physician supply versus emergency department volume. I will address from the federal level scope of practice of mid-level practitioners. Most importantly I will be willing to

COMMON SENSE JANUARY/FEBRUARY 2022

AM: The influence of corporate management groups and private equity in our practices have raised many concerns. In many emergency physician’s opinions, the emphasis on corporate profit over patient safety and physician wellness has led to an increasing incidence of burnout in our specialty. Can you share your thoughts related to these entities?

SA: Being the age that I am, I saw the start of CMGs. Some of the first were formed by a few of the original founders of emergency medicine. My first objection to those entities is they fought to allow any specialty to work in emergency departments and blocked the requirement of emergency medicine board certification. This was one of the main reasons I joined AAEM in 1993. We have a strong voice as a group of physicians through AAEM. Now with the rise of CMG residencies, we are seeing the possibility

of oversupply of emergency department physicians which could adversely affect our jobs and livelihood. I will work hard to mitigate these issues with advice from the members of AAEM. AM: Covid has been a real challenge for all Americans but emergency physicians have been on the front line in this fight since the pandemic began. Have your experiences during Covid changed any of your health care views? SA: I was lecturing at a critical care/emergency medicine conference in Park City, Utah in February 2020 when the first case of Covid was announced in the state of Washington. One of my friends asked the group if this was going to be a significant issue or a “nothing-burger?” About 50% said it will be bad while the other 50% said “a nothing-burger.” I am proud of our emergency department responses to this pandemic. I think as a specialty we have performed well on the front lines. I had two young physician friends die from Covid. We have lost nurses and others working in the emergency department. I do not know if we will ever get back to “normal,” but we are gradually improving. Covid has definitely changed the way I look at things. I want to thank each and every one of you for your work, care, and perseverance through this pandemic. AM: Sam, are there any other issues which you would like to share with your emergency medicine colleagues? SA: In my experience, I have come to realize that we must be vigilant in facing the issues. We must continually fight for our goals, for our rights in the practice of emergency medicine, for our patients’ rights, and for the ever important doctor-patient relationship. If we are not diligent, we, and especially our patients, will suffer. The old saying “for failure to occur, only requires good people to do nothing.” We are all blessed to have AAEM to represent our profession. We need to be involved in the politics of this country. Remember Plato said, “If we refuse to be involved in our politics, then we will be destined to be ruled by fools.”

GERIATRICS COMMITTEE

This Virus Stinks: Two Personal Stories Robert A. Frolichstein, MD FAAEM and Christopher Carpenter, MD MSc FAAEM AGSF

“Bob, it breaks my heart

but I don’t want you to come for Christmas.” Tears welled as I heard my mother speak those words in early November of 2020. Residency and my career in the Army and then in EM caused me to move away from my parents 30 years ago. In each of those years despite the miles and difficulties traveling with four children, we made it a point to spend several days around Christmas with my parents. Of course we made other visits but our annual trek to St. Louis at Christmas was part of our family holiday tradition. We drove through snowstorms or boarded planes with young children and all of the trappings and tribulations that entails. I found it hard to believe that this virus was going to be what proved to interrupt our tradition. I was not surprised, but was filled with grief and anger. I contemplated on how this virus has changed my life.

Once I got over myself, I focused on my Mom. I had been speaking with her frequently and understood she was being very careful. Doing all the right things—having groceries delivered, attending church services online, even limiting visits with my sister and her family who live near her. She desperately wanted us to come and bury the kids (now mostly grown) in warm embraces like every year before. She realized, however, that, although my kids were mostly doing the right thing to protect themselves from COVID-19, they were young adults still doing some young adult things. She recognized I was seeing COVID every day. She weighed the risk/benefit and decided the risk was too high. My father passed away about 10 years ago so she was truly alone, isolated almost every day. I know she yearned for anything to break her from her isolation. Her days were filled with eating alone, reading, maybe watching a movie or talking on the phone to some friends. He doctor visits were even all via telemedicine. This virus stinks. Not too long after she was fully immunized my oldest daughter got married. My sister and her family brought my mom for the wedding. Of course we were overjoyed to see her but also struck by her disability. She has some limitations because of some hip and back problems and COPD that is probably worse than what she acknowledges but is really pretty spry. It was a challenge for her to walk down the aisle. This was not my Mom. After her return to St. Louis my sister took her for a full cardiac evaluation as we believed she might have some undiagnosed valvular heart disease that was contributing to her disability. Nope. Everything checked out good. It turns out it is bad for you to sit in a chair day after day without any activity. My Mom began walking laps around the house and when the community prevalence of COVID was low enough began to go to church, visit with friends and live life. The turnaround in her condition has been remarkable. This virus stinks.

“He wants to leave AMA.” I was stunned. How could this man with

room air oxygen saturations less than his age of 68 leave AMA? He was on high flow oxygen just to keep his stats at 90. I explained to him that if he leaves he will die. He shook his head and said, “I can’t do it, we made a promise.” He explained to me that he and his wife had made an agreement that if either of them got COVID they would stay home and take care of each other the best they could knowing they might die. This was in the early days of COVID before we could arrange home oxygen and the hospitals had no visitors. They recognized that being admitted for COVID often resulted in death and they agreed that they were not going to die alone. I got his wife on the phone and the three of us talked about it. Ultimately, we agree that he would be admitted. We were at a hospital associated free standing emergency department with no inpatient beds so the ambulance was arriving to transport him to the hospital. She got in her car and drove to that admitting hospital. Luckily, I knew the EMS transport team and asked them to wait in the ambulance bay for her to arrive. They wanted to embrace, to look in each other’s eyes and say “I love you.” I saw that EMT a few days later and asked. A tear came to his eyes as he said, “Yeah, she made it and got to kiss him goodbye. Hopefully not forever.”



Yeah, she made it and got to kiss him goodbye. Hopefully not forever.”

This virus stinks!

>> COMMON SENSE JANUARY/FEBRUARY 20221

GERIATRICS COMMITTEE

These stories illustrate the isolation that is common

members of the AAEM Geriatrics Committee there is so work in these areas and others. What research are you aware of? What are your ideas? Please reach out to the geriatrics committee to get involved and explore all this unique issues of our geriatric population. If you want to share your stories, contact the Geriatrics Committee for help or advice if needed. The committee is interested in publishing a series of articles in Common Sense and you can help.

among the geriatric population even before COVID. Perhaps we can learn something from the light that COVID shed on this ongoing problem. I would love to hear what the community of physicians with a special interest in geriatrics are exploring as ways to combat the situation. Can the ED provide solutions to involve family members in their ED care plan remotely? Can the ED do more with the transition to home for geriatric patients after a stay in the emergency department? I know from discussions with

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COMMON SENSE JANUARY/FEBRUARY 2022

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SOCIAL EM & POPULATION HEALTH COMMITTEE

Outside the ED Walls: How One Ohio ED Responded to the Opioid Crisis by Opening a Clinic Lorado Mhonda, MS4 and Sara Urquhart, MS4 RN MA

his month, fourth year medical student Lorado Mhonda from Case Western Reserve University School of Medicine spoke with toxicologists Dr. Ryan Marino and Dr. Lauren Porter at University Hospitals (UH) in Cleveland, Ohio, about the Medication Assisted Treatment (MAT) Clinic they have spearheaded.

The historical paradigm has been to provide printed resources and let patients call and figure this all out on their own.”

LM: What is a Medication Assisted Treatment Clinic (MAT Clinic)? Dr. Marino: Our goal is to provide medications for initial treatment of addiction. There’s a lot more that can go into it than just medication but the most important would be buprenorphine. Our specific clinic goals have been to increase access and lower the barriers to access. We have our low threshold model which is on a weekly basis, patients can be seen within seven days. We’re currently using telemedicine for controlled substance prescribing which helps with the barrier of needing to be in person because a lot of people do not live close to the Case Western University Hospitals campus. One important point is that we’re not psychiatrists or specialists in addiction psychiatry and addiction medicine. When people need more intense psychiatric treatment and counseling, we refer them. The MAT Clinic is more for people who are just trying to get stabilized on things like buprenorphine. LM: What was the inspiration behind the idea to start the MAT Clinic? Dr. Porter: When we started our toxicology service here we quickly ran into the issue of realizing that the outpatient providers that were able

to see patients to prescribe suboxone were already really overworked and booking patients really far out, so it was hard for patients to get in to see them. That put patients in a really hard scenario where we would get them started on medications either in the emergency department or any inpatient side and then they wouldn’t have anyone to follow up with in a timely manner. With telemedicine increasing significantly and with UH increasing that, we kind of jumped on that. It’s been able to hopefully decrease some of those barriers to patients. Dr. Marino: The historical paradigm has been to provide printed resources and let patients call and figure this all out on their own. This is a particularly vulnerable patient population so being able to have something where the ED can refer them to us and they can be seen within a week was kind of our big motivation. LM:What steps did you take to start the clinic? Dr. Porter: We talked with the chair of our department, our business administrator, and some of our colleagues that work in the inpatient and outpatient world to see how they navigated their setup. We decided to work with our psychiatry colleagues, who usually managed our referrals. We joined their program and joined the psychiatry division and department under the addiction division of it, and then built our telemedicine structure from there. So it was actually easier than anticipated because we are just using a set up that had already been in the hospital system to begin with and really just kind of piggybacked on their model. The biggest thing that we used was their billing plan. Their billing team joined forces along with the emergency medicine department.

COMMON SENSE JANUARY/FEBRUARY 20221

COMMON SENSE JANUARY/FEBRUARY 2022

SOCIAL EM & POPULATION HEALTH COMMITTEE

LM: Were there any obstacles or challenges that you faced, and how were you able to overcome some of them?

Providing the opportunity for them to be able to follow up and get a monthly prescription allows me to make an impact on their life.”

Dr. Marino: There have been a lot of obstacles. I think some of the biggest ones are two big categories here would be regulations in regards to addiction as a whole and how we still have very inaccurate and inappropriate laws and policies on the books, specifically regarding buprenorphine. One of the issues is going to be when the pandemic exemptions expire, Ohio requires in-person visits to prescribe controlled substances and so that is going to be a big limitation. One of the other ones has been that these services are still not something that most payers want to cover and so there have been endless hoops to jump through requiring prior authorizations, refusing prescriptions, and having issues on nights and weekends. I’m not saying it’s terrible for me, I can survive that stuff, but it’s terrible for the patients that have to go through this and have no options and are contacting me at all hours of the day because they don’t have their medication.

Dr. Porter: I think a lot of the issues are things that all outpatient providers run into that we ED providers have been able to avoid. Patients come to us because they’re motivated and they want to stay in recovery but the laws are written by people that have no medical knowledge or training and this is the biggest hindrance to patient care. LM: How would you describe the impact of the program so far? Dr. Porter: I have a few longer term patients and then a few patients that bridge on to other providers after weaning off of medicine. I had a gentleman who relapsed after a very significant social change in his life and I’ve been seeing him now for about four months. He has been completely in recovery, is doing amazing, his wife has been taking extra classes to better learn his addiction and better understand how it’s been affecting him mentally and emotionally. I have a patient that has completely switched her life around—she moved to a different area, parenting, and working. Her life has completely done a 180. It’s been really inspiring to see to get that extra follow up with patients and the ones that we’ve been able to help have done well. Dr. Marino: I have a number of patients who lived far away from the hospital who had significant mobility issues from traumatic injuries that brought them into the hospital or things like joint infections. Providing the

opportunity for them to be able to follow up and get a monthly prescription allows me to make an impact on their life. Another thing that’s been cool is the shift in hospital culture. A lot of emergency physicians and other specialists are more interested in getting people started on buprenorphine and starting a conversation because they know they have somewhere they can send the patient to after discharge. LM: What are your future goals and directions for the MAT Clinic?

Dr. Porter: Expanding our hours is a goal. We’ve gone from no patients on some days to having completely full schedules and then adding extra hours on. So I think adding extra availability and providers to our program just to help improve access would be ideal. Dr. Marino: This initially was like the bridge clinic model where we just wanted to give people a short term stopgap coverage, but the ability to provide longer term coverage would be very nice. Outside of the clinic itself, we need future advocacy for fixing some of these broken systems and cooperation with politicians and insurers on those issues. LM: What advice would you give physicians or institutions that are thinking of implementing a similar program? Dr. Porter: You don’t need to reinvent the wheel. You have outpatient systems already set up, you have referral lines already set up and looking at this as any other medical subspecialty referral line is the easiest approach. I think people look at starting a whole new clinic and a whole new system as a very overwhelming thing when the reality is that the infrastructure is there. You don’t need huge amounts of money as far as setting up telemedicine. You just need motivated people. Dr. Marino: I think people should go for it. There’s always going to be reasons not to do this but it’s much easier than people think. It’s very rewarding and most importantly at the end of the day, this is evidence based.

References: 1. American Academy of Emergency Medicine: Management of Opioid Use Disorder in the Emergency Department - https://www.aaem.org/UserFiles/ file/AAEMOUDWhitePaperManuscript.pdf 2. Annals of Emergency Medicine: Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department - https:// www.annemergmed.com/article/S0196-0644(21)00306-1/fulltext

COMMON SENSE JANUARY/FEBRUARY 20221

WELLNESS COMMITTEE

Self-Compassion, Self-Valuation, and Boundary Setting in Emergency Medicine Al’ai Alvarez, MD*

any of us work multiple clinical shifts while also balancing time with friends and family. For those of us in academic practice, there are also never-ending deadlines for papers, national talks, and grant applications. There are also the learning modules we have to complete by the end of the year. While we can aim to be more efficient—and there are experts on this in emergency medicine (EM) such as Dr. Jennifer Kanapicki and Dr. Christina Shenvi— we must also acknowledge that the list will continue to expand, and there are only so many hours in a day. This is where boundary setting is essential. To start, it’s important to acknowledge that it is not easy to set boundaries. This takes practice and we will likely fumble more at the beginning. But we owe it to ourselves to try. Boundary setting requires that we learn how to say “No” to some commitments and opportunities. As EM physicians, we have high standards and expectations which often leads to compromising our own needs, such as time for ourselves or our family. Balance, therefore, equates to conflict. Dr. Kristen Neff has done a lot of work on self-compassion.1 She highlights three main components: • Self-kindness: the act of nurturing and showing tenderness to ourselves in our moments of struggle. • Common humanity: these moments of struggles are not unique to you alone, and suffering is a part of being human. • Mindfulness: having self-awareness of the experience of suffering without over-identifying with it. In her recent work, “Fierce Self Compassion,” Dr. Neff highlights the importance of also “acting in the world” to include “protecting, providing for, and motivating ourselves.” It refers to self-advocacy and standing up for ourselves, setting boundaries, and fighting for injustice.2

frustrated are all normal reactions to stress. Can we see how much of this is within our circle of influence? Can we safely see one more patient so we can somehow help with the overcrowding? We can also see how much of this is due to the inefficiencies in the system. Fierce self-compassion and boundary setting allow us to notice at the moment that we have the capacity to be intentional with our decisions. We can focus on our current patient load instead of sacrificing quality patient care just to increase the number of patients being seen. Or perhaps we can call for help. We can be clear about what it means to care for our patients vs. pathologic altruism that compromises our own well-being.

How does this translate to saying “No” to yet another committee project? How about managing an overcrowded emergency department?

Boundary setting is a form of self-compassion. In physician well-being literature, self-valuation refers to the “constructive prioritization of personal well-being and growth mindset perspective.” The same team did a multicenter study, which showed a clear dose-response relationship between self-valuation and burnout, and self-valuation and sleep-related impairment.3 Physicians with high self-valuation scores sleep better and have less burnout.

By practicing self-kindness, we focus on understanding our own needs as well. We are protecting our own well-being and providing ourselves with options, including the option to say “No.” Understanding the common humanity means that just like me, the number of responsibilities you currently have feels overwhelming and that you are not alone in experiencing this. Mindfulness allows us to have the clarity to decide what needs to be done right now, what can wait, and what we hope for ourselves.

Practicing self-compassion takes courage. Know that you are not alone in this experience, and when you leave the emergency department, there is no doubt that more patients will arrive. Self-compassion does not mean abdicating our role as physicians. It means advocating for our own well-being by developing clear boundaries so that we can be more effective and caring towards our patients and each other when we show up to work.

When the waiting room continues to fill up, we can notice this discomfort. We can acknowledge to ourselves that feeling anxious, angry, or 36

To start, it’s important to acknowledge that it is not easy to set boundaries.”

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WELLNESS COMMITTEE

References

We must recognize that as physicians, we are not superheroes. Just like our patients, we are also humans.” We can only focus on what we can control, and included in this, is doing our best. And also included in this is understanding our own limitations. As we begin to move towards Physician Well-Being 2.0, we must recognize that as physicians, we are not superheroes.4 Just like our patients, we are also humans.

* @alvarezzzy. Director of Well-Being and Co-Chair of the Human Potential Team, Stanford Emergency Medicine Vice-Chair, AAEM Wellness Committee 1. Neff KD. Definition and Three Elements of Self Compassion. Accessed November 30, 2021. https://self-compassion.org/the-three-elements-ofself-compassion-2/ 2. Neff KD. Fierce Self-Compassion by Kristin Neff. Self-Compassion. Accessed November 30, 2021. https://self-compassion.org/fierce-selfcompassion/ 3. Trockel MT, Hamidi MS, Menon NK, et al. Self-valuation: Attending to the Most Important Instrument in the Practice of Medicine. Mayo Clin Proc. 2019;94(10):2022-2031. doi:10.1016/j.mayocp.2019.04.040 4. Physician Well-being 2.0: Where Are We and Where Are We Going? Mayo Clinic Proceedings. Accessed November 30, 2021. https://www. mayoclinicproceedings.org/article/S0025-6196(21)00480-8/fulltext

AAEM-PG Welcomes Pacific Redwood Medical Group The American Academy of Emergency Medicine Physician Group (AAEM-PG) is pleased to welcome Pacific Redwood Medical Group (PRMG) as a member group. Pacific Redwood Medical Group is a longstanding democratic group that has provided outstanding services to several hospitals in Mendocino County, California. In order to be eligible for membership, PRMG had to demonstrate values consistent with the AAEM mission and vision statements of physician led care in a fair and equitable practice environment. The AAEM strongly believes patients are best served in such settings. PRMG sought out the AAEM-PG for administrative and practice management support that will help preserve its future as a well-run physician-owned group practice.

COMMON SENSE JANUARY/FEBRUARY 20221

WELLNESS COMMITTEE

Stop Normalizing the Abuse of Residents Brendan James Flanagan, MD

esidency is a notoriously brutal training process. The hours are long and the pay is inadequate. But one of the largest sources of moral injury to residents is the mistreatment that they experience throughout the course of their training. In addition to working too many hours for too little money, residents are plunged into a medical training culture that can only be described as abusive. Occupying the lowest spot in an organization that is obsessed with hierarchy, residents are routinely subjected to harassment, hostility and public humiliation from a variety of sources including attendings, colleagues, other hospital staff and, frequently, patients. In a recent survey published by the ACGME, nearly half of emergency medicine residents reported some type of workplace mistreatment in the past academic year.1 This disturbingly high number is still likely an underrepresentation, as many in our profession have simply come to accept this behavior as commonplace and others may fear retaliation for reporting these transgressions. In the world of academic medicine, there remains a pervasive ethos of character-building through abuse. The mistreatment of residents is seen not as an unfortunate byproduct of an antiquated medical training system, but rather, the purpose of the system itself. Enduring abuse from attendings, consultants, and other colleagues is supposed to give residents the thick skin that they will need to survive and thrive in our professional culture. But there is ample data to suggest that how we treat our trainees is more deleterious than salutary. Despite the prevailing culture, there is little evidence that the current model of aggressive training actually produces more resilient doctors and abundant evidence that it may be doing exactly the opposite. In the 2017 National Emergency Medicine Wellness Survey, an overwhelming majority of emergency medicine residents report symptoms consistent with burnout.2 Burnout itself has long been associated with a wide array of negative outcomes for both physicians and the patients they care for, including increased medical errors, worse 38

COMMON SENSE JANUARY/FEBRUARY 2022

clinical outcomes, and an increased incidence of depression, substance abuse, and suicide.3 While burnout is obviously multifactorial, there is evidence that residents who experience harassment are more likely to experience burnout symptoms and suicidal thoughts.4 Most disturbingly, it seems that when residents do experience abuse, they are very hesitant to report it for fear of retaliation from their superiors.5 Much of the misery of residency is tolerated because it is temporary. EM residents know that after three or four years they will become the attendings and enjoy the increase in money, status, and respect that they have earned from their hard work. What this fosters, however, is a cycle of abuse whereby today’s trainees who suffer from mistreatment often become tomorrow’s aggressors. Even physicians who do not abuse residents have been trained in a culture where doing so is considered normal and thus goes underreported and uncorrected. While many of us are not in a position to meaningfully change resident work hours or compensation, we can all do our part in changing medical culture and ending this cycle of abuse. All institutions should establish a zero-tolerance policy for abuse of any kind in the workplace. Mistreatment of trainees should be zealously identified and rooted out in much the same way as we approach patient safety events. Anyone who experiences or witnesses abuse should feel comfortable reporting the incident without fear of retaliation. Repeat offenders should not be insulated from professional consequences for their behavior because of their place in the medical hierarchy. Residents, along with everyone else in healthcare, deserve to be treated with compassion and respect and we should aim to model this behavior for those who will become the future leaders of our field.

While many of us are not in a position tomeaningfully change resident work hours or compensation, we can all do our part in changing medical culture and ending this cycle of abuse.”

References: 1. Lall, Michelle D., Karl Y. Bilimoria, Dave W. Lu, Tiannan Zhan, Melissa A. Barton, Yue-Yung Hu, Michael S. Beeson, James G. Adams, Lewis S. Nelson, and Jill M. Baren. “Prevalence of Discrimination, Abuse, and Harassment in Emergency Medicine Residency Training in the US.” JAMA Network Open 4, no. 8 (August 19, 2021): e2121706–e2121706. https://doi. org/10.1001/jamanetworkopen.2021.21706. 2. Lin, Michelle, Nicole Battaglioli, Matthew Melamed, Sarah E. Mott, Arlene S. Chung, and Daniel W. Robinson. “High Prevalence of Burnout Among US Emergency Medicine Residents: Results From the 2017 National Emergency Medicine Wellness Survey.” Annals of Emergency Medicine 74, no. 5 (November 2019): 682–90. https://doi.org/10.1016/j. annemergmed.2019.01.037. 3. Stehman, Christine R., Zachary Testo, Rachel S. Gershaw, and Adam R. Kellogg. “Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I.” Western Journal of Emergency Medicine 20, no. 3 (May 2019): 485–94. https:// doi.org/10.5811/westjem.2019.4.40970. 4. Hu, Yue-Yung, Ryan J. Ellis, D. Brock Hewitt, Anthony D. Yang, Elaine Ooi Cheung, Judith T. Moskowitz, John R. Potts, et al. “Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training.” The New England Journal of Medicine 381, no. 18 (October 31, 2019): 1741–52. https://doi.org/10.1056/ NEJMsa1903759. 5. Leisy, Heather B., and Meleha Ahmad. “Altering Workplace Attitudes for Resident Education (A.W.A.R.E.): Discovering Solutions for Medical Resident Bullying through Literature Review.” BMC Medical Education 16 (April 27, 2016): 127. https://doi.org/10.1186/s12909-016-0639-8.

OPERATIONS MANAGEMENT COMMITTEE

Where Have All the Nurses Gone? An Exploration of the Nursing Shortage and Proposed Solutions Akiva Dym, MD, Kraftin Schreyer, MD FAAEM, and Anthony Rosania, MD FAAEM

s the COVID-19 pandemic continues to spike across the United States and around the new world, a new crisis has emerged within healthcare systems — critical shortages of nursing staffing. At this time, hospitals in regions all across the US are dealing with the significant challenge of severe nursing staffing limits, requiring hospitals to reduce patient capacity and even close entire units due to staff shortages. According to the U.S. Bureau of Labor Statistics, close to 1.1 million new nurses will be required to meet the clinical demand as well as replace nursing retirees.1 However, it is expected that the nursing shortage will continue for the foreseeable future. So, where are the nurses? There are multiple factors which are contributing to the current nursing shortage, some of which are COVID related but many others which have been developing for a longer period of time.

Another major force contributing to nursing staffing shortages is the aging workforce. It has been projected that close to 500,000 experienced RN’s will retire by 2022, which will have a major effect on the current levels of nursing staffing.5 And, while nursing enrollment has been steadily increasing, the current nursing school capacity is far lacking as compared to the current demand required. Thus, a combination of increasing retirees with a lower rate of graduate replacements will only worsen our current nursing shortage. Nowhere has the nursing shortage been noted as painfully as within our emergency departments (EDs). EDs around the country are routinely being forced to either close entirely or limit capacity due to nursing shortages. Lack of ED nurses has been shown to contribute to delays in care, longer length of stay, and increased walk out rates, all of which contribute to adverse patient outcomes.6,7 The high work demand and burnout within the ED environment is often a driver for nursing staff to leave the ED, making it challenging to find consistent and seasoned staffing within the ED. Facing this new reality of nursing staffing shortages, EDs will have to come up with innovative and creative staffing models and throughput models in order to ensure optimal capacity and function of the emergency department, while still maintaining high levels of quality and safety for our patients.

SO, WHERE ARE THE NURSES?”

Certainly, COVID has accelerated the nursing shortage. While the early stages of the pandemic were exhaustive leading to some nurses taking the opportunity to retire, most nurses stood fast through the burnout. But, continued COVID surges after the vaccine rollout proved to be too much for many. Nurses sought alternative options that were less stressful, safer for themselves and their families, or, more lucrative. With increased demand for nursing staff in certain “hot spot” regions, an increasing number of nursing staff are joining the socalled “traveler” staffing agencies which are willing to pay higher salaries and signing bonuses to ensure staffing in specific regions. The higher pay, up to $150/hour and signing bonuses upwards of $20,000, have caused large volumes of nurses to seek alternate nursing options, thus exacerbating shortages in other regions.1

In addition to the COVID factors, nursing shortages are also being driven by a shift of nursing staff into other clinical roles. One such shift is from bedside nursing to nurse practitioner roles. Over the last 10 years, the number of nurse practitioners has grown by double-digits year after year.2 There has been a continued drive from leading nursing organizations encouraging this transition, which has also accelerated the nursing shortage.3 Furthermore, many nurses are shifting from hospital-based roles to other clinical roles, such as out-patient clinic and long-term care, again, contributing to shortages within hospital practice.4

While it is important to ensure fair compensation, financial solutions can only do so much when there is a shortage of resources, especially if the financial solutions divert nurses away from the areas they may be needed most. We propose that physicians can do their part to improve the workplace environment for their nursing colleagues, and hopefully mitigate some of the current problems.

Physicians should additionally respond by encouraging the following: • Partnering with nursing leadership and organizations to develop a robust, multidisciplinary approach to workforce issues. • Engaging technology fully to offload cognitive and task burdens.

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OPERATIONS MANAGEMENT COMMITTEE

Organizations must recruit chief nursing informatics officers and make reducing this burden a strategic priority them. Appropriate use of LPNs, technicians, phlebotomists, and other support staff can allow our highly trained RNs to function as a leader of a nursing care team — allowing a “force extension” of their knowledge and skill without sacrificing patient safety.

Nurses, while central to the process, will not be able to solve this alone.”

Lastly, nurses must be adequately reimbursed and incentivized for delivering highly skilled and safe patient care. It is uncommon for nursing incentives to be aligned with the very value based programs that their institutions benefit from financially. At the same time however, we must ensure that incentives do not create an undue burden on our safety net hospitals, who may not be able to compete financially with wealthier institutions.

• Looking for opportunities to create “nurse extender” roles using LPNs, medical technologists, and paramedics when appropriate and safe to do so. • Ensuring financial incentives focus on the most critical areas and patients in a way that is socially responsible and does not exacerbate health inequities. Each of the above interventions is critical to solving this problem in a way that is realistic, forward thinking, and equitable. Offloading work to non-nurse providers and staff requires engagement of those partners in a meaningful way. Nurses, while central to the process, will not be able to solve this alone. Addressing the ever increasing burden created by electronic health records on our nursing staff is equally critical. In the author’s experience, it is often too easy for the answer to meaningful use or regulatory check points to be to increase the burden of nursing documentation.

AAEM22

PRE AND POST CONFERENCE COURSES Post-Conference Courses Cadaver Based Procedures Lab ECG in the ED

COMMON SENSE JANUARY/FEBRUARY 2022

While the nursing shortage will likely be an ongoing problem in US health care, the sooner we can do our part, the sooner we can create an environment that sustains the health care team and keeps our patients safe.

References: 1. https://www.aamc.org/news-insights/hospitals-innovate-amid-dire-nursingshortages 2. https://www.healthaffairs.org/do/10.1377/hblog20180524.993081/full/) 3. https://pubmed.ncbi.nlm.nih.gov/24983041/ 4. https://www.aamc.org/news-insights/hospitals-innovate-amid-dire-nursingshortages 5. https://fortune.com/2021/05/18/nurse-shortage-retirement-crisis-covidtraining-leadership/ 6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5942016/ 7. https://www.nytimes.com/2021/08/21/health/covid-nursing-shortage-delta. html

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WOMEN IN EMERGENCY MEDICINE

A Q&A with Dr. Gillian Battino: A Physician Running for the US Senate for the State of Wisconsin** Danielle Goodrich, MD FAAEM FACEP and Molly Estes, MD FAAEM FACEP

n addition to the health care struggles over the last nearly two years, there has also been a shift in local and national politics. Politics plays a major role in health care in determining everything from access to care to vaccine implementation. Now, more than ever before, there is a need for advocacy on behalf of our patients, ourselves, and our specialty. To get an insider’s view, we sat down via zoom with Dr. Gillian Battino, a practicing physician and mother of five, currently running for the US Senate for the State of Wisconsin.* DG: How did you get involved in public health and politics? GB: In 2009, I had this ground shifting epiphany. I was in a private practice, the only woman in the practice, and there was just a complete lack of professional and personal respect. I was really kind of heartbroken because I had invested a lot of time and heart into the practice. I was told if you wanted to be a woman in this game then you had to play at the highest possible level, you had to be better than the boys to be respected. So, I did this crazy thing where I quit my job. I had no plan but I knew I wanted to do something different with my life. This is one of the best decisions I’ve ever made. But I’m grateful for my own courage to say I’m not tolerating this, I can’t see my way around it, and I’m going to re-invent my career. After making a major career change to breast imaging, and at the prompting of my new program, I started to pursue global health. My first initiative was starting a RAD-AID chapter, which is focused on developing radiologic services in low-middle income countries. We started a successful program in Nicaragua and through this I started feeding my soul. Over the last six years, we’ve built the first radiology residency training program in Guyana, modeled after Vanderbilt University, who built the first emergency medicine training program in the country. Then, four to five years ago, I began thinking, who do I want to see in political leadership? I was not seeing the changes I wanted to see by my representatives. At the time, I took care of a young 30-year-old woman who presented with a fungating breast mass. She was holding her 3-year-old child on her lap and worried about paying her bill. I thought, this is so wrong. The problems I have been thinking about and working on internationally are right here in my own country. Part of the problem right now is that we don’t have enough women in medicine, physicians in the senate, and very poor representation at all. So, I realized that it is a person like me, who has been navigating difficult obstacles and political scenery for over ten years and getting stuff done, who should be running for politics. Certainly, the pandemic makes people highly sensitive to the needs of public health care. The public wants people who understand medicine and public health representing them.

ME: What are some practical ways a physician can get involved and start making a difference? GB: The first thing is finding the right balance and keeping your eyes open for opportunities to advocate. There are often advocacy opportunities through your national organizations by joining the political advocacy committee (PAC) or government I realized that it is a person like policy committee. If you have me, who has been navigating difficult children, joining the school board is a natural thing, particularly right obstacles and political scenery for now, when the voices of scienover ten years and getting stuff done, tists, parents, and doctors who are who should be running for politics.” on the frontlines are so important. Working on your city council or county board are other ways. I would like to see a change in our medical education that offers a rotation in policy and public health and advocacy. DG: What do you wish you knew before getting into politics? GB: The hardest part about starting the campaign was putting together a team. There are groups who provide political training, particularly for women candidates. Unfortunately, I wasn’t able to get plugged in with one but I do recommend going that route because it would help in making those inroads and connections. I relied on word of mouth and adding one team member at a time. My biggest wish for anyone doing this is support from their spouse and their employer. ME: How do you manage to do it all? What’s your secret? GB: Be really honest with what you need from your family and be a communicator. Find the support where you can. Make sure you have people who are supportive on your team like family and coworkers. I try to include my kids in everything I do, all my kids have been to Nicaragua except my youngest. I wanted to make sure they were able to get involved and they set up their own community service projects working with local schools or kids’ groups. If getting involved is something you are interested in doing, we encourage you to reach out to your local city, county, or state governments to see what positions may be open for you to serve. You can also reach out to your state or regional chapters of AAEM to find out more information on how we, as physicians, can advocate for change. To learn more about Dr. Battino, visit https://battinoforsenate.us/, follow her on Twitter at @battino4senate, or on Facebook at Dr. Gillian Battino for US Senate. *The interview has been modified for length and clarity. **After publication Dr. Battino announced she was running for State COMMON SENSE JANUARY/FEBRUARY 20221 Treasurer of Wisconsin

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COMMON SENSE JANUARY/FEBRUARY 2022

AAEM/RSA PRESIDENT’S MESSAGE

It’s Match Season! Lauren Lamparter, MD

t is match season— the most exciting, terrifying, and confusing season of medical school. Matching is the ultimate goal of medical school, perhaps even bigger than just graduating. Now, you’ve interviewed, participated in awkward zoom socials, and had to explain the process to family members and friends more times than you can count, and this period of waiting until that third Friday in March can feel like months instead of weeks. As a current intern, my memories of the hope and anxiety surrounding the match are still very fresh, and I’m so grateful to be on the other side, training at an awesome program. You soon will be too! Last year, by the end of the interview process I had five programs that I really loved. They were spread clear across the country and were different in almost every aspect. As I wrestled with my final rank order, I wished I could create a combination of the programs or divide my time between them. I followed what everyone recommended—considered the locations, the people, the training sites, the board preparation, the alumni networks, and of course the “gut feeling.” However, the problem with trying to find “your one” in a match process is that in creating a rank order, you inherently are set up to feel disappointed, or even rejected, when you go lower down your list than you “planned.”

…and this period of waiting until that third Friday in March can feel like months instead of weeks.”

In 2021, 78.7% of all residency applicants matched, and the average length of their rank lists was 13.98 programs.1 These stats are incredibly encouraging and show us that you have a decent chance of matching after about 12-14 interviews. What they don’t show, however, is that whichever program you decide is your first choice is actually fairly unlikely to be your final match. In emergency medicine, there were 2,840 residency spots available, 3,734 residency applicants, and ultimately, 2,826 matches occurred.2 This means that 75% of emergency medicine applicants matched, but it does not specify where on their list they matched. As a student who interviewed at 12 programs, you can have confidence that statistics are in your favor for finding a match, but you inherently have to be prepared that you could match at any of your programs.

false expectations can be dangerous. My first few programs were in a city close to my family, and I allowed myself to dream about seeing them in the afternoon after a long shift, or for a few hours on a holiday when I had worked the night before. On Match Day, I simultaneously experienced excitement and grief with the result. I was so excited that I matched at the program that continued to steal my heart through the entire application process, but I had to work through the grief of continuing to be far from my family. I think these dichotomous emotions surround Match Day for most people, regardless of how low you match.

Where I ultimately matched was the program that moved the most through my rank list. As you can probably guess, it did not end up as my first rank. I wanted to write this article about my experience because the extensive waiting time of this process allows you to dream, and

As you await your match, I want you to be prepared for both the ex- >> citement and the possibility for heartache. The match is a very unique, difficult process. I truly don’t believe there is one perfect program, and wherever you end up, you will have the opportunity to become an

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AAEM/RSA PRESIDENT’S MESSAGE

excellent emergency medicine physician. I think it is more common than people care to admit that they do not match at their first choice. However, as a product of the match, I do think that this process works to facilitate a good program to applicant fit. Whatever your match results, you will have the opportunity to find your purpose at that program and lean into your potential to become a great doctor. Good luck with the match!

References 1. https://www.nrmp.org/wp-content/ uploads/2021/08/Impact-of-Length-of-ROLon-Match-Results-2021.pdf 2. https://www.nrmp.org/wp-content/ uploads/2021/08/Advance-DataTables-2021_Final.pdf

COMMON SENSE JANUARY/FEBRUARY 2022

On Match Day, I simultaneously experienced excitement and grief with the result.”

AAEM/RSA EDITOR

Insensible Losses Kasha Bornstein, PGY1 MD MPH MSc Pharm EMT-P*

uring my fourth year of medical school, I rotated in the coronary care unit at my local county safety net hospital. It was the height of the first wave of COVID in Florida, and the CCU was adapted into a mixed cardiac and non-COVID medical intensive care unit to handle overflow. Alongside a skeleton crew of residents and some very adaptable cardiologists, I embarked on a month-long ICU crash course in a converted pediatric post-op ward. I managed patients with complications of myocardial infarctions—many of whom had avoided the hospital at the height of their chest pain due to COVID fears—as well as delirious septic patients, patients with asthma-related respiratory failure, and gastrointestinal hemorrhages in the setting of cirrhosis. Under-resourced, I stepped into a brand-new role of being a primary caretaker of many of the sickest patients I’d ever seen. I learned the basics of hemodynamics, about resuscitation and maintenance fluids, about insensible losses.

Like many other epidemics, COVID-19 has both magnified and exposed the societal effects of structural racism and other paradigms of structural violence. Low income, essential labor that cannot be done from home, and multigenerational housing has exposed more communities of color to illness and mortality throughout this pandemic, insensible losses of which the effects will be felt for generations to come. Just a few months into my residency training, I’ve had numerous regrettable experiences of disclosing to families the death of their young family member due to gun violence or a drug overdose. In those moments, I find the health care workers around me uniformly sympathetic to the children who have lost a parent or a sibling. When I consider the negativity and stigma that surrounds the care of patients who present with chronic, untreated mental illness or dangerous drug use, I can’t help but think what losses occurred for our patients that are insensible for us? How can we integrate awareness of those traumas into our care?

All too often we individualize population-wide disease processes, placing the blame on individuals for their ‘poor decisions’ rather than recognizing that people often make the most reasonable decisions from a limited set of options.”

Insensible losses refer to the body fluids lost daily that are not easily measured, from the respiratory system, skin, and water in the GI tract. As I arrived each day to peruse the census, I started to recognize a different sort of insensible loss. I began noticing a trend in our critically ill patient demographics. Our city was unique, one of a relatively short list of large US cities where people of color comprise the majority of the population. Only a tiny proportion of the patients I cared for were white. The average age of those few white patients was around eighty years old, while many of the patients of color I saw in the terminal stages of chronic illness were in their fifties or sixties. This phenomenon matched large-scale lifespan projections in which the average life expectancy at birth for a Black baby born in our city was fully five years fewer than the population average.1,2 In New Orleans, where I’m training as an EM/IM resident, life expectancy can vary by as much as 15 years depending on one’s zip code. As I saw these trends play out in both datasets and in the daily census, I began to ask myself, what are the effects of these insensible losses? What does it mean socioeconomically to lose a grandparent and the years of low-cost childcare they can provide? In the years of chronic illness and worsening disability preceding death, what are the generational effects of losing another wage-earner in the home? How do we fail to measure these effects when we see these patients in our emergency departments?

In a recent interview, United States Surgeon General Vivek Murthy spoke to the insensible losses that have come about as a result of COVID-19: There are profound, invisible prices that we have paid, wounds that we have sustained during this pandemic. And we talk about what’s easy to see and measure—number of hospitalizations, cases, deaths, number of schools that have had to close, number of people who lost their job—these are very important consequences. But they are part of a broader set of consequences, which include the impact on people’s mental health, on their identity and sense of self, on their sense of connection to other people, and on their sense of purpose.3 As Dr. Murthy eloquently notes, it can be difficult to comprehend the structural forces that our patients navigate throughout their lives, particularly in the short periods of time that we come to know them. We may appropriately recognize that their demographics play a role in the illnesses they are exposed to but, missing the forest for the trees, we may attribute risk to race rather than racism. Investigation into redlining, intentional deprioritization for mortgage lending and neighborhood segregation over the 20th century, reveal profound health consequences for Black communities and other communities of color. These are amplified by the COVID pandemic. There are statistically significant associations between greater

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AAEM/RSA EDITOR

Like many other epidemics, COVID-19 has both magnified and exposed the societal effects of structural racism and other paradigms of structural violence.” redlining and pre-existing conditions for heightened risk of morbidity in COVID-19 patients like asthma, COPD, diabetes, hypertension, high cholesterol, kidney disease, obesity, and stroke.4 All too often we individualize population-wide disease processes, placing the blame on individuals for their “poor decisions” rather than recognizing that people often make the most reasonable decisions from a limited set of options. 100,000 people making the same dangerous decision ought not be seen as 100,000 individual dangerous decisions. There are

systemic forces that impel dangerous choices and systemic problems require systemic solutions. If we bear that in mind during our patient encounter and afterwards, we may be able to more effectively address the unique problems that poverty and racism create for our patients. As the lowest barrier to health care settings across the United States, how will we make our emergency departments sites for remedying these effects?

References: * Louisiana State University Internal Medicine/Emergency Medicine Program 1. Miami Life Expectancy Methodology and Data Table. Center of Society and Health. Virginia Commonwealth University. Published 2014. https:// societyhealth.vcu.edu/media/society-health/pdf/LE-Map-Maimi-Methods.pdf. 2. Rojas D, Melo A, Moise IK et al. The Association Between the Social Determinants of Health and HIV Control in Miami-Dade County ZIP Codes, 2017. J. Racial and Ethnic Health Disparities 8, 763–772 (2021). https://doi.org/10.1007/s40615-020-00838-z 3. On Being. https://onbeing.org/programs/vivek-murthy-and-richarddavidson-the-future-of-well-being/ 12/2/2021 4. Nelson RK, Ayers EL. “Not Even Past: Social Vulnerability and the Legacy of Redlining,” The Digital Scholarship Lab and the National Community Reinvestment Coalition. American Panorama. https://dsl. richmond.edu/socialvulnerability.

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Now I am the Master: Transitioning from Learner to Teacher

YOUNG PHYSICIANS SECTION

Alan Sazama, MD

n the classic Star Wars film “A New Hope,” former apprentice, and now evil villain, Darth Vader, comes across his old teacher Obi-Wan Kenobi for the first time in years and states, “The circle is now complete. When I left you, I was but a learner. Now I am the master.” Now, let’s hope that none of you use your well-earned residency training to go on and become evil Sith lords bent on ruling the galaxy. Even if galaxy domination isn’t your cup of tea, when the all-important step from resident to attending occurs, we can appreciate the sentiment of becoming a “master” overnight. The attending physician security blanket who increasingly throughout training became your “just in case” is now you! Let’s look at some tips to making this big transition as smooth as can be.

Trust your Training

Set the Tone

Graduating from an accredited emergency medicine residency training program gives you a special set of skills that not many possess: trust that gift! The stressful nights cross-covering in the ICU, shifts in the ED where you felt in over your head, and whiffing on an important procedure only to be rescued by a senior resident are all experiences that have crafted you into a “master,” a highly skilled emergency medicine physician. There are still plenty of

One of the more important roles as attending will be setting the tone for your team on shift. As a physician, you will be looked to as the leader of the unit, perhaps in a way that is different than you experienced as a senior resident. Positive energy is contagious. Residents, students, nurses, and even your new colleagues will be watching as you interact with challenging consultants, advocate for admission on your patients, deal with demanding patients, and provide education to your team. Be worth looking up to. Gaining the respect of the entire care team doesn’t have to be something that takes years of practice if done the right way. Think of your training; it’s probably not hard to think of the attending physicians who were “favorites” of staff, consultants, and patients. What characteristics did they have? Did they remain calm amidst the storm that can sometimes be an ED shift? Were they kind to all the staff, from the housekeepers to the chair of surgery? Did they provide effective constructive criticism for improvement without being condescending? Strive each shift to set a positive tone no matter what an ED shift throws your way.

Now, let’s hope that none of you use your well-earned residency training to go on and become evil Sith lords bent on ruling the galaxy.”

Realize Master does not equal Perfect While it is true that you are now the go-to person in the unit, you are not expected to, nor will you ever truly be, a perfect master of the craft. Disease, specifically emergent disease, complicates practice by being surprising, unique, and challenging. Sometimes not knowing exactly what to do next is not an indictment of the training you received, but rather an acknowledgement of a craft that is forever challenging no matter the number of years out from training. While you will be sought out by others as a leader for your expertise, know that the teachers you had in residency in the form of nurses, consultants, patient care techs, and social workers will remain some of your best educators. A good “master” will still rely on the team for their insight and wisdom.

“what do I do now?” procedures that don’t go as well as you wanted or feelings of just being overwhelmed, but know that your senior colleagues with much more experience and time out from residency feel the same thoughts from time to time. Your training has prepared you for this moment, not only to practice high-quality emergency medicine but also to impart your knowledge to residents, medical students, and your staff.

Take the Time Being in community practice myself, this is probably one of the hardest parts of being a teacher that was a bit easier in the academic setting. Teaching takes time to do well. There will be colleagues who are less interested in spending time with medical students, off-service residents, and maybe even ED residents. When you feel the burden of moving patients,

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doing procedures, and managing full waiting rooms, it sure can be hard our field about the burnout that physicians, even young physicians, are to listen to a drawn-out medical student presentation, teach an off-serexperiencing. Educating the next generation of students and residents vice resident how to do a laceration repair, or explain to a new intern and seeing things click as they take care of emergency patients can be how to talk with a specialty service on the phone. However, taking the one of the tools in our belt to combat the burnout epidemic. Our job can time to do these things will pay dividends for their be frustrating as days fill with bureaucracy, electronic medical records, metrics, and non-clinical education. Balancing the responsibilities of being responsibilities, leading us to forget some of the an attending physician with being a teacher may wonder we experienced as we intubated for the get more challenging as time passes and responEducating the next generation of sibilities accumulate. However, developing good students and residents and seeing first time, learned how to work up an abdominal teaching habits early will be important to long-term pain patient, or felt pride in seeing a patient who things click as they take care of success. was dying in front of us leave the hospital with emergency patients can be one of their family. We remember being learners—let’s Transitioning from learner to teacher provides great the tools in our belt to combat the use our skills to be quality masters for those who opportunity for professional growth while presenting burnout epidemic.” are still learning. challenges. There has been a lot of discussion in

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Captivating Capnography – The Basics of EndTidal CO2 Benjamin Rezny, DO FAAEM* and Andrew Winkleman, OMS-II†

apnography is most known for its use in confirming endotracheal tube placement and assessing the effectiveness of CPR. However, there are several other clinical scenarios where end tidal CO2 (ET-CO2) can provide us useful information.

Anatomy of an ET-CO2 waveform Before discussing uses of ET-CO2, we must understand the normal capnography waveform. A normal ET-CO2 waveform can be divided into four separate phases reflecting different stages of both inhalation and exhalation (Fig. 1a). The waveform takes on a quadrangular-shaped appearance. In the first phase, baseline CO2 is near zero with inhalation of gas entering the airway. As exhalation begins, so does phase 2, with CO2 levels rising from the mixing of gases between the anatomical dead space and alveolar dead/ventilated space. The most clinically relevant phase is phase 3 since this is where the actual ET-CO2 is measured. Phase 3 represents the alveolar plateau where there is a balance between ventilation and perfusion thus maintaining constant CO2 levels. The last portion of phase 3 is the plateau. This is the maximum concentration of CO2 and is also where the measured value for ET-CO2 is obtained. In phase 4, CO2 levels fall rapidly after the onset of the next inspiration. Understanding the basic waveform is important because any deviation could indicate a variety of potential problems involving cardiac output and respiratory function, for which we will now explore further.1–5

Confirmation of endotracheal tube placement Capnography is a rapid and effective method of confirming endotracheal tube placement when compared to other methods. Pulse oximetry, for example, takes a longer time to detect oxygen desaturation.2,6 Observing for endotracheal tube condensation can also be inaccurate, since it is present in up to 80% of esophageal intubations.7 Failure of proper tube placement is a common problem in the emergent care setting since as many as 5-10% of intubation attempts result in misplacement of the tube into the esophagus, causing increased morbidity and mortality.8 Proper tube placement can be confirmed within seconds using waveform capnography, by observing elevated CO2 levels and a rectangular waveform. This indicates proper wave placement as compared to absent CO2 levels and lack of waveform as occurs with esophageal intubation.3,5,6 (Fig. 1b)

Effectiveness of CPR Interruptions in CPR to assess rhythm and return of pulse worsen outcomes.4 In accordance with 2020 American Heart Association ACLS guidelines, capnography can be an important quantitative method, in

addition to clinical assessments, to provide real time feedback on the quality of CPR and return of spontaneous circulation.9 Waveforms with an ET-CO2 of greater than 20 mmHg indicate adequate chest compressions, in a patient that still viable tissues, while an ET-CO2 less than 10 mmHg signals inadequate technique or possible provider fatigue.3,4 If ET-CO2 levels remain below 10 mmHg for a prolonged period, despite good compressions, then return of spontaneous circulation is highly unlikely. This can be taken into account when determining futility of further resuscitative efforts.10 However, factors that affect cardiac output or the effectiveness of ventilation must be taken into consideration if there is a low ET-CO2 during CPR. These include myocardial infarction, hemorrhagic shock, and pneumothorax.3 If ET-CO2 levels rapidly rise to normal values (35-45 mmHg) then return of spontaneous circulation is likely.11 The use of capnography for CPR should be used in addition to other management methods and not alone.12

Cardiac Output Methods such as the passive leg raise (PLR) have been shown to be effective in monitoring fluid response in cases of shock. However, PLR requires a direct measure of cardiac index and relies on multiple factors such as echocardiography, arterial line waveforms or other invasive monitoring.4,13 If no instrument is accessible to analyze the effects of PLR on cardiac index, then ET-CO2 can be an alternative method.3,13 ET-CO2 changes caused by PLR have been shown to be better predictors of fluid responsiveness compared to arterial pulse pressure variations caused by PLR.3,4,13–15 Studies have shown that mechanically ventilated patients who are responsive to fluids, will have an ET-CO2 increase of more than 5 percent.3,4,13–16 Additional studies exploring the relationship between capnography and fluid response will likely be an area of future investigation.

Respiratory Capnography has been shown to have a potential role when it comes to recognizing COPD and pulmonary embolism (PE). Difficulties exist with diagnosing a PE in both the ICU and emergency department, which often CTA scan is the gold standard and test of choice.3,4 Potential risks such as new cardiopulmonary complications can arise while waiting and transporting patients to get a CT scan.4 Other CT limitations include contrast use being relatively contraindicated in pregnancy, renal disease, and allergic reactions.17 Thus, capnography can be used as a potential, noninvasive, alternative method to increase suspicion of PE. When using capnography in evaluating a PE, the ET-CO2 is expected to decrease due to the increase in alveolar dead space thereby decreasing the amount of CO2 exhaled.3,4 In patients with relatively normal pulmonary physiology at baseline, using the differences between the displayed ET-CO2 and PaCO2

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obtained from an ABG (late dead space fraction) could be suggestive of PE if this fraction exceeds 12 to 15 percent.3,18–20 (Fig. 1c) This fraction has further potential to be applied as a method of further assessment in low-risk PE patients as determined by Wells score.3,21,22 When looking at the third phase in the waveform for COPD or asthmatic patients, a steeper slope is associated with the severity of airflow obstruction resembling a shark fin waveform appearance.3,4 (Fig. 1d) Because of this, capnography could have the potential in distinguishing between COPD and heart failure in an emergency medicine setting, by using a multitude of factors such as exhalation duration, end-exhalation ET-CO2 slope, and maximum ET-CO2 duration.3,4 Figure 1 Title: “End-Tidal CO2 Capnography Waveforms”

Procedural Sedation Procedural sedation is a common practice in the emergency department and ICU. Changes in ET-CO2 of > 10%, loss of capnography waveform or an increase of ET-CO2 above 50 mmHg has been shown to precede hypoxia by a median time of 60 seconds.23 It is important to note that although respiratory depression may cause hypercapnia, hypocapnia is equally concerning. Progressive hypocapnia secondary to reduced tidal volumes, specifically a decrease from baseline ET-CO2 by more than 10 mmHg or loss of waveform are indicative of a patient at risk for developing severe respiratory depression.24

COVID With the high prevalence of COVID, the need for rapid diagnostic testing has resulted in the development of rapid COVID tests. Although not useful in the rapid detection of COVID, capnography may prove helpful in monitoring the severity and progression of COVID infection. As alluded to above, capnography has already been shown to be able to differentiate between different pulmonary diseases like COPD, asthma, PE and heart failure. Since the initial COVID presentation is often respiratory, capnography holds promise in being a simple, noninvasive method to rapidly assess the severity COVID. Capnography can provide real time monitoring and assessment of COVID patients, by evaluating changes to the waveforms such as slopes, shape changes, and duration at ET-CO2.25 Many limitations exist such as limited data, distinguishing waveform characteristics of COVID from other pulmonary diseases, requiring further investigation.

Conclusion Capnography is not just limited to CPR and endotracheal tube placement. ET-CO2 is likely underutilized and developing a basic understanding of the various waveforms will help enhance your clinical practice and care of critically ill ER and ICU patients.

References * University of Iowa Carver College of Medicine † Kirksville College of Osteopathic Medicine

Legend: a) displays the normal ET-CO2 waveform illustrating the four phases. b) esophageal intubation – note the lack of quadrangular waveform, the ET-CO2 is below the expected 40 mmHg. c) pulmonary embolism – phase 3 plateaus around 25 mmHg, this waveform combined with a normal PaO2 should raise suspicion for a pulmonary embolism. d) the classic “shark fin” appearance of an obstructive process

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1. Benumof JL. Interpretation of capnography. AANA J. 1998;66(2):169-176. https://pubmed.ncbi.nlm.nih.gov/9801479/. Accessed November 28, 2021. 2. Bhavani-Shankar K, Philip JH. Defining segments and phases of a time capnogram. Anesth Analg. 2000;91(4):973-977. doi:10.1097/00000539200010000-00038 3. Long B, Koyfman A, Vivirito MA. Capnography in the Emergency Department: A Review of Uses, Waveforms, and Limitations. J Emerg Med. 2017;53(6):829-842. doi:10.1016/J.JEMERMED.2017.08.026 4. Nassar BS, Schmidt GA. Capnography During Critical Illness. Chest. 2016;149(2):576-585. doi:10.1378/CHEST.15-1369 5. Manifold CA, Davids N, Villers LC, Wampler DA. Capnography for the nonintubated patient in the emergency setting. J Emerg Med. 2013;45(4):626-632. doi:10.1016/J.JEMERMED.2013.05.012 6. Nagler J, Krauss B. Capnography: a valuable tool for airway management. Emerg Med Clin North Am. 2008;26(4):881-897. doi:10.1016/J. EMC.2008.08.005 >>

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7. Kelly JJ, Eynon CA, Kaplan JL, De Garavilla L, Dalsey WC. Use of Tube Condensation as an Indicator of Endotracheal Tube Placement. Ann Emerg Med. 1998;31(5):575-578. doi:10.1016/S0196-0644(98)70204-5 8. Sakles JC, Laurin EG, Rantapaa AA, Panacek EA. Airway Management in the Emergency Department: A One-Year Study of 610 Tracheal Intubations. Ann Emerg Med. 1998;31(3):325-332. doi:10.1016/S01960644(98)70342-7 9. Craig-Brangan KJ, Day MP. AHA update: BLS, ACLS, and PALS. Nursing (Lond). 2021;51(6):24-30. doi:10.1097/01.NURSE.0000751340.92329.AE 10. Salen P, O’Connor R, Sierzenski P, et al. Can cardiac sonography and capnography be used independently and in combination to predict resuscitation outcomes? Acad Emerg Med. 2001;8(6):610-615. doi:10.1111/j.1553-2712.2001.tb00172.x 11. Falk JL, Rackow EC, Weil MH. End-Tidal Carbon Dioxide Concentration during Cardiopulmonary Resuscitation. N Engl J Med. 1988;318(10):607611. doi:10.1056/nejm198803103181005 12. Heradstveit BE, Sunde K, Sunde GA, Wentzel-Larsen T, Heltne JK. Factors complicating interpretation of capnography during advanced life support in cardiac arrest-A clinical retrospective study in 575 patients. Resuscitation. 2012;83(7):813-818. doi:10.1016/j. resuscitation.2012.02.021 13. Monnet X, Bataille A, Magalhaes E, et al. End-tidal carbon dioxide is better than arterial pressure for predicting volume responsiveness by the passive leg raising test. Intensive Care Med. 2013;39(1):93-100. doi:10.1007/S00134-012-2693-Y 14. Lakhal K, Nay MA, Kamel T, et al. Change in end-tidal carbon dioxide outperforms other surrogates for change in cardiac output during fluid challenge. Br J Anaesth. 2017;118(3):355-362. doi:10.1093/BJA/AEW478 15. Young A, Marik PE, Sibole S, Grooms D, Levitov A. Changes in end-tidal carbon dioxide and volumetric carbon dioxide as predictors of volume responsiveness in hemodynamically unstable patients. J Cardiothorac Vasc Anesth. 2013;27(4):681-684. doi:10.1053/J.JVCA.2012.09.025 16. Toupin F, Clairoux A, Deschamps A, et al. Assessment of fluid responsiveness with end-tidal carbon dioxide using a simplified passive leg raising maneuver: a prospective observational study. Can J Anaesth. 2016;63(9):1033-1041. doi:10.1007/S12630-016-0677-Z

17. Robert-Ebadi H, Righini M. [Diagnosis of pulmonary embolism]. Rev Mal Respir. 2011;28(6):790-799. doi:10.1016/J.RMR.2010.10.039 18. Olsson K, Jonson B, Olsson CG, Wollmer P. Diagnosis of pulmonary embolism by measurement of alveolar dead space. J Intern Med. 1998;244(3):199-207. doi:10.1046/J.1365-2796.1998.00356.X 19. Eriksson L, Wollmer P, Olsson CG, et al. Diagnosis of pulmonary embolism based upon alveolar dead space analysis. Chest. 1989;96(2). doi:10.1378/CHEST.96.2.357 20. Anderson JT, Owings JT, Goodnight JE. Bedside noninvasive detection of acute pulmonary embolism in critically ill surgical patients. Arch Surg. 1999;134(8):869-875. doi:10.1001/ARCHSURG.134.8.869 21. Hemnes AR, Newman AL, Rosenbaum B, et al. Bedside end-tidal CO2 tension as a screening tool to exclude pulmonary embolism. Eur Respir J. 2010;35(4):735-741. doi:10.1183/09031936.00084709 22. Sanchez O, Wermert D, Faisy C, et al. Clinical probability and alveolar dead space measurement for suspected pulmonary embolism in patients with an abnormal D-dimer test result. J Thromb Haemost. 2006;4(7):15171522. doi:10.1111/J.1538-7836.2006.02021.X 23. Deitch K, Miner J, Chudnofsky CR, Dominici P, Latta D. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med. 2010;55(3):258-264. doi:10.1016/J.ANNEMERGMED.2009.07.030 24. Miner JR, Biros MH, Heegaard W, Plummer D. Bispectral electroencephalographic analysis of patients undergoing procedural sedation in the emergency department. Acad Emerg Med. 2003;10(6):638-643. doi:10.1111/J.1553-2712.2003.TB00048.X 25. Malarvili MB, Alexie M, Dahari N, Kamarudin A. On Analyzing Capnogram as a Novel Method for Screening COVID-19: A Review on Assessment Methods for COVID-19. Life (Basel, Switzerland). 2021;11(10):1101. doi:10.3390/LIFE11101101

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Is there a need for lumbar puncture to rule out subarachnoid hemorrhage if a head CT scan is negative? 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

Introduction Headache is a common complaint in the emergency department (ED).1 Because of the high associated mortality, spontaneous subarachnoid hemorrhage (SAH) is an important diagnostic consideration in the evaluation and workup of these patients.1 Current recommendations by emergency medicine and neurosurgery societies are for patients to undergo a lumbar puncture (LP) after a negative non-contrast head computed tomography (CT) to evaluate for SAH, although LPs may not always performed due to multiple factors including patient fear, clinical barriers such as the time needed to perform, and low diagnostic yield.1,2 Due to time constraints, the invasiveness of the procedure, and increased ED length of stay, the need for LP comes into question as imaging technologies such as thin-slice non-contrast CT, CT angiography (CTA), as well as magnetic resonance imaging (MRI) continue to advance.2

Clinical Question What is the utility of LP in the diagnosis of subarachnoid headache compared to other diagnostic modalities?

McCormack RF, Hutson A. Can computed tomography angiography of the brain replace lumbar puncture in the evaluation of acute-onset headache after a negative noncontrast cranial computed tomography scan? Acad Emerg Med. 2010;17(4):444-451. The authors of this paper present a mathematical probability model to evaluate CT/CTA as a method of evaluating patients who present with acute-onset headache within 48 hours of onset with a normal neurologic exam. This model was developed based on review of existing literature examining SAH prevalence in ED patients as well as the sensitivity of CT for evaluation and diagnosis. Inclusion criteria were patients with a normal neurologic exam and lack of significant risk factors for cerebral aneurysm. Additionally, the investigators focused on studies with SAH due to cerebral aneurysm or arteriovenous malformation (AVM), due to the better prognosis associated with other etiologies. Based on their literature review, they assumed a 12.75% rate of SAH due to aneurysm or AVM in patients with acute onset headache. For diagnostic performance, the authors chose one representative study looking at CT for SAH3 and one study examining CTA for cerebral aneurysm or AVM in patients diagnosed with SAH4 to make their calculations. They used a 91% sensitivity (95% CI 92-97%) for CT in patients with a normal neurologic exam,3 and 98% sensitivity and 100% specificity for 64-slice CTA for aneurysm detection in the setting of SAH.4 For LP sensitivity, they cited a single study finding 100% sensitivity and 67% specificity for LP in diagnosing SAH.5 52

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After making the above assumptions and selecting their representative studies, the authors determined that with both a negative CT and CTA, the posttest probability of there being neither SAH nor aneurysm was 99.98%, with a 95% CI of 99.75-100%. Importantly, they recognized that CT and CTA results could be dependent on each other and therefore recalculated the posttest probability assuming 25, 50, and 75% dependence of the two tests, all of which remained above 99%. The major identified downside of adopting a CT/CTA model is the risk of additional testing and anxiety if a patient is found to have a technically incidental nonbleeding aneurysm. The largest limitation of this study is that it is all theoretical and has not been validated using actual patient data. The authors highlight the infeasibility of a true comparison study of CT/LP and CT/CTA due to the large number of patients (at least 3,000) required for appropriate study power, but suggest a more achievable future study of 30-130 patients to examine the dependence relationship between CT and CTA to further strengthen their model. In the time of shared-decision making, the authors advise that if CT and CTA are both negative, patients should be counseled that the risk of missed SAH from aneurysm or AVM is less than 1%, noting this statistic may reduce the number of patients willing to undergo LP after both negative tests. It is worth noting that although SAH from other etiologies has better outcomes, it may be unsatisfactory to the patient or physician to miss these diagnoses, depending on their personal risk tolerance.

Carpenter CR, Hussain AM, Ward MJ, et al. Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Metaanalysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds. Acad Emerg Med. 2016;23(9):963-1003. Carpenter et al sought to perform a systemic review and meta-analysis of studies evaluating the various diagnostic tools and clinical decision rules for SAH, as well as delineate the probability of disease thresholds for imaging and lumbar puncture. Studies were included if they described adults (age 14 years or older) with an acute headache or other symptoms or signs leading to SAH as a diagnostic consideration. The authors define “disease positive” as the presence of acute SAH, including non-aneurysmal SAH, as well as a positive LP, defined as an erythrocyte count (RBC) above 1000 x 106/L in the final tube as well as either visible or spectrophotometric xanthochromia. Patients with negative imaging in whom LP was not performed were

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categorized as “disease negative” only in studies attempting follow-up after hospital discharge. Studies that solely reported data on patients with SAH were excluded. Out of an initial 5022 studies identified, 122 underwent full review with 22 studies ultimately included.

Gill HS, Marcolini EG, Barber D, Wira CR. The Utility of Lumbar Puncture After a Negative Head CT in the Emergency Department Evaluation of Subarachnoid Hemorrhage. Yale J Biol Med. 2018;91(1):3-11.

The authors found there was no significant element of history that carried a very high pooled positive likelihood ratio (defined as a LR > +10). The findings on history that increased the probability included subjective neck stiffness (LR+ = 4.12, 95% CI = 2.24 to 7.59) while the probability was reduced in the absence of the “worst of headache of life” (LR- = 0.36, 95% CI = 0.01 to 14.22) or onset of headache over more than one hour (LR- = 0.06, 95% CI = 0 to 0.95). On physical exam, neck stiffness (LR+ = 6.59, 95% CI = 3.95-11.00) was strongly associated with SAH, but the authors remarked on the significant heterogeneity on which these history and physical characteristics were defined.

This multi-center, hypothesis-blinded, retrospective study examined the therapeutic and practical yield of performing LPs following a negative non-contrast head CT. Out of all patients undergoing ED LPs between September 2007 and September 2012 a total of 1282 LPs were performed. Patients were excluded if there was a prior history of SAH, prior neurosurgical procedure, central nervous system neoplasm, prior ED visit for headache within one month of involving CT or LP, a presentation continuous with post-dural puncture headache, or transfer from outside hospital system with a diagnosis of SAH. A total of 342 charts met the inclusion criteria: >18 years of age, non-traumatic headache lasting <14 days, no focal neurological deficits, LP performed in the ED and interpreted by an emergency physician, and a negative head CT.

For non-contrast CT, authors noted sufficient accuracy to rule in or rule out SAH within the first six hours of symptom-onset, with a pooled sensitivity of 100% (95% CI = 98% to 100%, I2= 0%) and LR- of 0.01 (95% CI 0 to 0.04, I2 = 0%). Findings on LP of xanthochromia performed differently on pooled analysis depending on whether the xanthrochromia was defined by visual (sensitivity 85%, specificity 97%) or spectrophotometric (sensitivity 100%, specificity 95%) evaluation. The presence of RBC >1000 x 106/L carried a pooled sensitivity of 76% and specificity of 88%. The authors commented on problems associated with LP including frequent traumatic taps, delay in xanthochromia development, and occurrences of post-LP headaches. The authors concluded by incorporating the risks and benefits of both testing and continued investigation into the decision analysis, the benefits of LP are unlikely to outweigh the harm across a wide range of reasonable estimates of pretest disease prevalence. The meta-analysis found that only patients with a pre-CT likelihood of SAH well above 20% were likely to benefit from an LP after a negative dry CT but the authors noted that such high pre-CT probabilities are unlikely due to the limited performance of history and physical examination. The main limitations of this review were the significant heterogeneity in the manner were collected and reported, such as the generation of the CT scanner used, and the mechanisms of the follow-up for the patients. Overall, the authors concluded that within six hours of symptom onset, noncontract CT accurately both rules in and rules out SAH. The role of lumbar puncture perhaps less necessary with the improvement of multislice CT/CTA technology and increasing evidence refuting the utility of LP. The authors pointed out clinical decision rules such as the Ottawa SAH rule still require external validation but can assist in risk stratify ED headache patients to identify subsets most likely to benefit from post-computed tomography lumbar puncture, CTA, or no further testing. They suggested future studies to quantify the diagnostic accuracy of history and physical examination as well as visible or spectrophotometric assessment of xanthochromia for the diagnosis of SAH.

This study found that while 44 (12.9%) of the 342 LPs demonstrated xanthochromia, only five (1%) were ultimately diagnosed with SAH and none of the patients with SAH had an aneurysmal source of bleeding detected on CTA. Lastly, the study found a 4.1% LP complication rate, with 13 post-lumbar puncture headaches and one epidural hematoma, and an increase in ED length of stay by an average of 2.7 hours. The authors of this study argue that LPs to rule out SAH in neurologically-intact patients after a negative head CT have low therapeutic yield (as there were no aneurysmal detections nor significant neurosurgical interventions in the small group with SAH), and can lead to unnecessary complications and a prolonged ED course. While this study challenges current guidelines, the inclusion criteria did not differentiate patients in whom SAH was the primary diagnostic consideration versus other diagnoses such as meningitis. Furthermore, a non-traumatic LP is user-dependent and it is unclear whether traumatic taps affect the final diagnosis of SAH. Lastly, the retrospective chart review nature of this study has inherent biases and limitations.

Chee C, Roji AM, Lorde N, et al. Excluding Subarachnoid Haemorrhage within 24 hours: to LP or not to LP? Br J Neurosurg. 2021;35(2):203-208. Based on the results of previously mentioned studies, there has been a general consensus that a negative head CT within six hours of headache-onset can effectively rule out SAH. However, CT technology has continued to improve and may have improved diagnostic accuracy. This retrospective review at a single center in the United Kingdom from 2012 to 2015 examined whether the timeframe could be extended with third-generation CT scans. The authors identified adult patients (>16 years old) presenting with acute nontraumatic headache with features suspicious for SAH (sudden-onset occipital headache, photophobia, neck stiffness, or nausea/vomiting). Of the 1884 patients identified over the study period, 999 patients met inclusion criteria. There was no gold standard, however, by which the investigators were able to define the

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AAEM/RSA RESIDENT JOURNAL REVIEW

presence of SAH and in the study it was defined as either having evidence of blood in the subarachnoid space on original CT imaging or an aneurysm identified on further neuroimaging (CTA or MR angiography). Of the 999 patients included, 179 (or 17.9%) patients total were diagnosed with SAH. The vast majority of them (176) were identified on initial head CT while the other three were diagnosed on further neuroimaging. The vast majority (97.4%) of patients with a negative CT underwent LP to assess for xanthochromia. One of the 21 patients who were discharged after negative initial CT without further workup was later readmitted with evidence of SAH and died. Of the 111 patients with positive or equivocal LPs, only three were found to have evidence of SAH or aneurysm on further imaging. Based on their findings, the authors concluded that within 24 hours of symptom onset, a negative initial head CT could effectively rule out SAH, calculating a sensitivity of 100% (95% CI 92.5-100). Even after 24 hours, they calculated a sensitivity of 94.5% (95% CI 86.6-98.5). While the authors’ conclusions sound enticing, it is unclear if their data is sufficient to change practice. First, their data would only apply to centers where third-generation CT and neuroradiologists are readily available. There was no gold standard for diagnostic certainty of SAH, and many patients with equivocal LPs did not get further rule-out imaging. The possibility of missed SAH in these instances may have lead to overestimating the sensitivity of noncontrast head CT. The time of onset of symptoms was unknown for the patient with the negative head CT who returned with SAH and died after discharge.

Bianchi C, Ageron FX, Carron PN. Assessment of diagnostic strategies based on risk stratification for aneurysmal subarachnoid hemorrhage: a retrospective chart review. Eur J Emerg Med. 2021 Oct 1;28(5):355-362. doi: 10.1097/ MEJ.0000000000000804. PMID: 33709998. Ottawa Subarachnoid Hemorrhage Clinical Decision Rules is a level two clinical decision tool to allow clinicians to rule out SAH as a cause of an acute nontraumatic headache.8 It stratifies the intermittent risk of SAH and the need for supplementary investigations. Current guidelines recommended a noncontract computed tomography (NCCT) followed by a lumbar puncture for the diagnosis of aneurysmal subarachnoid hemorrhage. In this study, Bianchi et al aimed to validate alternative investigative strategies through clinical risk stratification and the need to perform lumbar punctures within each risk stratification category. In a single-center, retrospective study, 310 patients were examined who presented with an acute headache and had a lumbar puncture, NCCT, and CTA. In the absence of high-risk criteria (focal neurological deficits, history of SAH or neurovascular abnormalities, cocaine consumption, or connective tissue disease), patients were ranked according to the Ottawa score to identify those at low risk versus intermittent risk. Low risk (Ottawa score of 0) was associated with an estimated pretest probability of SAH <0.3% and did not pursue further testing. Within the intermittent risk group (Ottawa score > 0), time intervals between headache onset and time of examination further stratified the patients. Three strategies were statistically assessed for the investigation of suspicion of SAH 54

COMMON SENSE JANUARY/FEBRUARY 2022

–NCCT followed by a lumbar puncture if the NCCT was negative (strategy 1 or current guidelines), combined NCCT and CTA followed by lumbar puncture if CT was negative and time from onset of a headache to the first CT was >12 h or high-risk clinical assessment (strategy 2) or time from onset of a headache to the first CT was >24 h or high-risk clinical assessment (strategy 3). Forty-two patients presented with high risk and 268 with intermediate risk. Eight patients had a final diagnosis of SAH. Compared to strategy 1, strategies 2 and 3 had a higher positive predictive value (89%) and negative predictive value (100%) and had a relative reduction of 57% lumbar punctures. The systemic addition of a CTA to NCCT was concluded to improved sensitivity of detection of SAH up to 24 hours from symptom onset. The authors concluded that the strategy of NCCT plus CTA, without a systematic lumbar puncture, within 24 hours of the onset of headache is well tolerated in intermediate-risk patients and with no missing diagnosis of SAH. The authors pointed out the study was underpowered with only 310 cases included in a single-center design. In addition, selection bias with clinicians in charge deciding which diagnostic tests to perform and selecting the cases by lumbar puncture performed excluded all potentially major SAH. CTs were systematically analyzed by one senior radiologist, but not always by a neuroradiologist. In addition, there was no systemic comparison between strategy 2 and strategy 3. The authors noted further prospective and multicenter trials are needed to confirm the benefits of CTA. However, this study poses a potential diagnostic strategy to avoid systemic lumbar puncture within the first 24 hours of symptoms’ appearance with the systemic addition of CTA and risk stratification approach.

Conclusion Lumbar puncture carries a high sensitivity in the rule-out of subarachnoid hemorrhage. With modern day improvements in imaging technology, the test thresholds for LP may become more precise with a need for a postCT LP in more selective acute headache patients. Emergency physicians will need to consider each patient’s specific pretest probability and balance their personal level of risk tolerance, as well as employ shared decision-making with their patients, when deciding whether or not to pursue LP in patients with a negative head CT early in their presentation. There is a very broad differential for a patient with a severe headache; lumbar puncture will continue to remain a part of the work-up for many patients until further larger studies demonstrate its lack of utility due to more advanced clinical imaging.

Answer A noncontrast head CT, when performed even up to 24 hours after symptoms onset, approaches a high sensitivity in ruling out subarachnoid headache, with CT angiography increasing the sensitivity even further. There remains a subset population in which an LP will be necessary to rule out a subarachnoid hemorrhage given that it is still part of standard care in the ED; the several studies mentioned here are not an indication

AAEM/RSA RESIDENT JOURNAL REVIEW

for a full change in standard of practice at this time.

References 1. Gill HS, Marcolini EG, Barber D, Wira CR. The Utility of Lumbar Puncture After a Negative Head CT in the Emergency Department Evaluation of Subarachnoid Hemorrhage. Yale J Biol Med. 2018;91(1):3-11. Published 2018 Mar 28. 2. McCormack RF, Hutson A. Can computed tomography angiography of the brain replace lumbar puncture in the evaluation of acute-onset headache after a negative noncontrast cranial computed tomography scan?. Acad Emerg Med. 2010;17(4):444-451. doi:10.1111/j.1553-2712.2010.00694.x. 3. Byyny RL, Mower WR, Shum N, Gabayan GZ, Fang S, Baraff LJ. Sensitivity of noncontrast cranial computed tomography for the emergency department diagnosis of subarachnoid hemorrhage. Ann Emerg Med. 2008;51(6):697-703. doi:10.1016/j.annemergmed.2007.10.007 4. Agid R, Lee SK, Willinsky RA, Farb RI, terBrugge KG. Acute subarachnoid hemorrhage: using 64-slice multidetector CT angiography to “triage” patients’ treatment. Neuroradiology. 2006;48(11):787-794. doi:10.1007/

s00234-006-0129-5 5. Perry JJ, Spacek A, Forbes M, et al. Is the combination of negative computed tomography result and negative lumbar puncture result sufficient to rule out subarachnoid hemorrhage?. Ann Emerg Med. 2008;51(6):707-713. doi:10.1016/j.annemergmed.2007.10.025 6. Chee C, Roji AM, Lorde N, et al. Excluding subarachnoid haemorrhage within 24 hours: to LP or not to LP?. Br J Neurosurg. 2021;35(2):203-208. doi:10.1080/02688697.2020.1781055 7. Carpenter CR, Hussain AM, Ward MJ, et al. Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds. Acad Emerg Med. 2016;23(9):963-1003. doi:10.1111/acem.12984 8. Perry JJ, Stiell IG, Sivilotti ML, et al. High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study. BMJ. 2010;341:c5204. Published 2010 Oct 28. doi:10.1136/ bmj.c5204

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COMMON SENSE JANUARY/FEBRUARY 2022

Continue reading on page13. OUR PATIENTS, OUR SPECIALTY: AAEM VERSUS ENVISION

Before the merger, AMSURG owned and operated two hundred and fifty-six (256) ambulatory

surgery centers and one surgical Hospital and owned Sheridan, a physician services company

similar to EmCare. After the merger, Envision Healthcare Corporation combined and rebranded

the two companies' physician services arms. In doing so, EmCare and Sheridan were combined

into Envision Physician Services L.L.C. In 2017, Envision Healthcare Corporation sold its

ambulance unit to Kohlberg Kravis Roberts (“K.K.R. ") a private equity firm with over $100

billion under management for $2.4 billion.

8 9

20.

Envision Physicians Services holds itself out to the public as a multispecialty

physician group and healthcare management team with over 25,000 clinicians and 1,600

employees operating at over 780 hospitals.

physicians, such as billing and collection, communication with vendors, and financial reporting.

Envision Physician Services was formed in Delaware on October 4, 2017. It was registered to do

business in California on December 20, 2017, by its sole member Envision Healthcare

Corporation. Envision Physician Services’ initial registration in California listed its address 1A

Burton Hills Boulevard, Nashville, TN, which is Envision Healthcare Corporation's corporate

headquarters. Envision Physician Services 2019 statement of information updates its corporate

address to be 7700 W. Sunrise Boulevard, Plantation, FL. Envision Physician Services' initial

registration and each subsequent statement of information were signed by Envision Healthcare

Corporation's General Counsel, Craig Wilson. The next year, in 2018, K.K.R. purchased the rest

of Envision Healthcare Corporation for $9.9 billion. Thereafter Envision Healthcare Corporation

was no longer publicly traded.

22 23 24

21.

It provides practice management services to

Envision Healthcare Corporation and Envision Physician Services L.L.C. shall

collectively be referred to herein as "Envision." 22.

Because California (as with the law of many other states) bars lay entities from

owning physician practice groups, Envision's business model and practice is to purchase, control,

and/or create a separate subsidiary legal entity for each hospital emergency practice or group of

practices it controls. The subsidiaries are managed and operated by people who are employed by

or and directly connected to the parent corporation, Envision. A medical director of the physician

COMPLAINT FOR UNFAIR BUSINESS PRACTICES (BUSINESS AND PROF. CODES § 17200 AND FOR INJUNCTIVE AND DECLARATORY RELIEF - 5 COMMON SENSE JANUARY/FEBRUARY 20221

OUR PATIENTS, OUR SPECIALTY: AAEM VERSUS ENVISION

entity is appointed, and the choice is made by Envision. Decisions are not made by the medical

directors. The medical practices owned or controlled by Envision shall be referred to as

Envision’s "controlled medical groups.”

23.

One such controlled medical group is Glass Beach Medical Services, a Medical

Corporation ("Glass Beach").

address as 6363 So. Fiddlers Green Circle, Suite 1400, Colorado. Charles T. Mitchell, M.D. is an

emergency physician practicing in the State of Hawaii who, on information and belief, merged an

emergency department practice with EmCare/Envision in approximately 1999. 6363 So. Fiddlers

Green Circle is or was an Envision corporate office and is listed as the address for numerous

medical and medical transport companies related to Envision Healthcare Corporation. Thereafter,

subsequent statements of information for Glass Beach Medical Services were signed by Craig A.

Wilson, Envision Healthcare Corporations' former General Counsel who is listed as Glass Beach's

Secretary. Glass Beach’s 2019 statement of information lists as its chief executive officer Brian

Jackson, Envision Physician Services L.L.C.'s former President. Finally, its chief financial officer

is listed as Kristy Rutherford, who was enterprise vice president treasury for Envision Healthcare

Corporation. None of the corporate officers listed on its 2019 statement of information are

licensed to practice medicine, and they each list their address as Envision Physician Services

corporate office at 7700 W. Sunrise Boulevard, Plantation, FL.

24.

It was formed in 2016 by Charles T. Mitchell, M.D. listing its

PLEP is a Physician owned and controlled professional corporation consisting of

emergency department physicians practicing emergency medicine in Placentia Linda Hospital’s

emergency department before 2021. PLEP contracted with Plaintiff AAEMPG to provide

practice management services for its Placentia Linda ED contract. The practice management

services provided by AAEMPG specifically exclude all activities described in the definitions of

the practice of medicine as set forth in the medical practice act where the Client's Hospital(s) are

located. PLEP maintained exclusive control of clinical decisions, and most of AAEMPG's

services to PLEP were optional and at PLEP's direction.

27 28

25.

In 2021, as a result of the acts alleged herein, Placentia Linda Hospital awarded

its E.D. contract to Glass Beach instead of PLEP, resulting in the termination of PLEP and its

COMPLAINT FOR UNFAIR BUSINESS PRACTICES (BUSINESS AND PROF. CODES § 17200 AND FOR INJUNCTIVE AND DECLARATORY RELIEF - 6 58

COMMON SENSE JANUARY/FEBRUARY 2022

OUR PATIENTS, OUR SPECIALTY: AAEM VERSUS ENVISION

1 2

contract with AAEMPG. 26.

In May of 2021, Glass Beach filed an updated statement of information identifying

Douglas Smith M.D. as its Chief Executive Officer. Douglas Smith M.D.’s address is listed as

7700 W. Sunrise Blvd., Plantation Florida, Envision Physician Services corporate headquarters.

Douglas Smith, M.D., is the President of Envision Physician Services. Plaintiff is informed and

believes that Douglas Smith, M.D. or his functional equivalent at Envision, is the C.E.O. of

hundreds of medical groups controlled by Envision Physician Services. He is not licensed to

practice medicine in California. Plaintiff is informed and believes Envision further ensures

corporate control of its controlled medical groups by having the named physician owner sign a

Stock Transfer Agreement which prevents them from having actual control of the entity. It is

believed these separate agreements include restrictions on the ability of the named physician

owner to issue dividends, create additional stock, or sell the medical group.

13 14

27.

Glass Beach provides services for which payment may be made in whole or in part

under California Welfare and Institutions Code Division 9, Part 3, Chapters 7 and 8.

15 16

Providing Kickbacks to Acquire Emergency Medicine Exclusive Contracts.

28.

Hospital Emergency departments in California are, except for narrowly specified

exempt entities, staffed by physician groups that work under agreements commonly known as

exclusive emergency services contracts. Hospitals grant such contracts to a medical group to

ensure continuous physician coverage of their emergency departments.

29.

The exclusive contracts are typically two or three years in duration. The group of

physicians who receive the contract have the exclusive right to treat patients at the emergency

department. Physicians who are not members of the group holding the exclusive contract are

excluded from treating patients in such emergency departments.

30.

Hospitals are generally able to choose among competing physician groups in

awarding such exclusive contracts. Since exclusive emergency services contracts guarantee a

continuous flow of patients, granting such a contract constitutes a referral of patients under

California. Therefore, such contracts may not be sold by the Hospital or purchased by physicians,

COMPLAINT FOR UNFAIR BUSINESS PRACTICES (BUSINESS AND PROF. CODES § 17200 AND FOR INJUNCTIVE AND DECLARATORY RELIEF - 7 COMMON SENSE JANUARY/FEBRUARY 20221

OUR PATIENTS, OUR SPECIALTY: AAEM VERSUS ENVISION

1 2

nor may consideration be offered or exchanged for the granting or renewal of such agreements. 31.

Envision offers to and/or provides consideration to Hospitals and hospital systems

in exchange for exclusive emergency department contracts grants. It offered and/or did provide

Tenet Healthcare with anesthesia services and/or hospitalist services without subsidies at Tenet

hospitals within the State of California (and nationwide) in exchange for Tenet granting it

exclusive Emergency department contracts. Subsidies are stipends that Hospitals provide to

certain hospital-based physicians or professionals as an incentive for them to practice at a hospital.

Tenet purchases the emergency contracts by agreeing to provide the Hospital with an anesthesia

group without the necessity of a stipend. Plaintiff is informed and believes this kickback scheme

10 11

is one of its standard methods of acquiring new contracts and maintaining existing ones. 32.

Envision offered to provide such unsubsidized anesthesia services to a Tenet

Hospital in 2021 for the Placentia Linda Emergency Department contract. The Hospital awarded

the contract to an Envision-controlled medical group, Glass Beach and failed to renew its

agreement with PLEP.

33.

Plaintiff is informed and believes that Envision offers or provides other

consideration to acquire exclusive E.D. contracts, including offering remuneration to physicians

who control physician groups to induce transfer of Emergency Department contracts to its

controlled medical groups and is informed and believed it offered remuneration to acquire the

contract at Placentia Linda.

Control Over the Practice of Medicine.

34.

After it acquires a practice and at all other times, Envision exercises profound and

pervasive direct and indirect control and/or influence over physicians' practice of medicine. Such

control diminishes physician independence and freedom from commercial interests, in violation

of California's corporate practice of medicine ban.

35.

Envision decides how many and which physicians will be hired, their

compensation, and their work schedule. Envision controls and/or influences advertising for

physician vacancies, vetting physicians, establishing the terms of employment, scheduling the

hours physicians will work, staffing levels, the number of patient encounters, and working

COMPLAINT FOR UNFAIR BUSINESS PRACTICES (BUSINESS AND PROF. CODES § 17200 AND FOR INJUNCTIVE AND DECLARATORY RELIEF - 8 60

COMMON SENSE JANUARY/FEBRUARY 2022

OUR PATIENTS, OUR SPECIALTY: AAEM VERSUS ENVISION

conditions. Envision decides when to terminate physicians and denies them rights to appeal via

traditional medical staffing mechanisms.

36.

Envision negotiates payor contracts with health insurers that pay physicians their

fees. Physicians are not made aware of the terms of those contracts. Envision requires physicians

to assign their rights to the proceeds of their medical billings to Envision then determines what is

charged to patients and insurers. It controls coding decisions and bills patients and or insurers for

such medical services. Envision physicians do not see what is billed and remitted in their names.

Because Glass Beach provides services for which payment may be made in whole or in part under

California Welfare and Institutions Code Division 9, Part 3, Chapters 7 and 8, Envision receives

remuneration under those code sections as well. Plaintiff is informed and believes that Envision

earns amounts from the physician's billings that exceed the reasonable value of the billing and

any other administrative services Envision provides and is therefore participating in what amounts

to illegal fee-sharing with a lay entity.

37.

Envision collects billings and has the benefit of all the revenues of its controlled

medical groups. Its certified public accountants who audit the financial statements of controlled

groups attribute all of their revenues to Envision and treat those revenues as income to Envision

for accounting and tax purposes.

38.

Envision establishes and promulgates physician "best practices," "red rules," and

"evidence-based pathways” protocols which enumerate standards for treating patients and are a

form of clinical oversight. It creates "benchmarking" reports that compare physician performance

to Envision-created standards, with the intention of modifying and interfering with the exercise

of their independent medical judgment. Envision tracks physician medical decision-making and

then provides "practice improvement feedback" in the form of reports which are designed to

"educate" physicians to practice medicine and make decisions that increase amounts charged to

patients.

39.

Envision's corporate control allows it to increase billings to patients, insurers, and

third-party payors for the physician services. These lead to modifications in the way care is

given. It has been the subject of multiple lawsuits against it nationwide for excessive billings. COMPLAINT FOR UNFAIR BUSINESS PRACTICES (BUSINESS AND PROF. CODES § 17200 AND FOR INJUNCTIVE AND DECLARATORY RELIEF - 9 COMMON SENSE JANUARY/FEBRUARY 20221

OUR PATIENTS, OUR SPECIALTY: AAEM VERSUS ENVISION

40.

Defendants, additionally, profit by reducing physician compensation, increasing

the number of patients that physicians see per hour, and increasing the utilization of physician

assistants to replace more costly physician coverage. Envision advertises to prospective hospital

clients that physician assistants are two-thirds less costly than physicians.

Use of Restrictive Covenants.

41.

Envision requires its physicians to execute restrictive covenants that state the

physician may not attempt to assist or cause any other emergency medicine group medical

practice to replace Envision. These provisions constitute further control and independently

constitute a violation of Business and Professions Code § 16600.

10 11 12 13 14 15 16 17 18 19 20

42.

The Glass Beach agreement provides the physician will not:

"(i) directly or indirectly induce or persuade (or attempt to induce or persuade) any person or entity (including any health care entity) to terminate its contract with any affiliates, subsidiaries, or managed entities thereof, Envision Healthcare Company, or any affiliates, subsidiaries, or managed entities thereof, or (ii) other than as an independent contractor of Company, solicit to provide any medical or management services to any hospital or medical facility at which medical services are provided by Contractor hereunder. In addition, for twelve (12) months following termination of this Agreement, Contractor shall not directly or indirectly induce, persuade (or attempt to induce or persuade) any person or entity to terminate or breach any contract with Company, any affiliates, subsidiaries, or managed entities thereof, Envision Healthcare Company, or any affiliates, subsidiaries, or managed entities." 43.

Plaintiff is informed and believes that all of Envisions' or its controlled medical

groups' contracts with physicians have covenants that are as restrictive as Glass Beach's contract,

if not more.

44.

By barring physicians from forming a group to compete with Envision or agreeing

to work for any other medical group that is soliciting or will solicit the exclusive contracts held

by Envision controlled groups, Envision or its controlled medical groups restrict a physician's

ability to practice their profession, limit physicians’ employment options, and ability to work for

other groups. Many of the locations where Envision holds emergency department contracts in

COMPLAINT FOR UNFAIR BUSINESS PRACTICES (BUSINESS AND PROF. CODES § 17200 AND FOR INJUNCTIVE AND DECLARATORY RELIEF - 10 62

COMMON SENSE JANUARY/FEBRUARY 2022

OUR PATIENTS, OUR SPECIALTY: AAEM VERSUS ENVISION

California, including Placentia Linda, have a limited number of emergency departments and thus

a limited number of employment opportunities.

45.

Envision intends and is aware their restriction has this effect of restraining

competition and requires physicians to sign a false disclaimer in their agreements that they can

"earn a reasonable living in the area in which they reside" to seek to immunize their agreement.

46.

Barring physicians from participating in unseating or competing for an Envision

contract also violates public policy. It limits a hospital's ability to choose the best emergency

group and gives Envision an unfair and almost insurmountable advantage in retaining exclusive

contracts in perpetuity. Hospital staff generally like working with the emergency department

group they have known for years; an essential part of obtaining a new contract is a promise most

of the emergency department physicians will be retained. Physicians' mobility is restrained during

the critical one-year time after their departure from a group by being barred from competing for

the contracts at Hospitals where Envision operates.

47.

The provision has the effect of reducing competition in the business and trade of

emergency department physician services, reducing the number of competitors for Emergency

Services Contracts, limiting the supply of emergency physicians available to patients seeking

emergency services, and causing increases in the price of such patient services by limiting the

facilities where emergency physicians can practice.

48.

The non-competition provisions are unfair competitive practices under business,

and Prof. Code 17200 et seq and violate public policy. They interfere with a hospital’s ability to

obtain any physician group they determine could provide the best medical care, effectively

preventing the Hospitals from retaining physicians currently working in the emergency

department for one year.

49.

The non-competition provisions serve no legitimate proprietary interests. E.D.

contracts are not assets that may be legally bought or sold. To the extent Envision paid for the

exclusive E.D. contract, as set for in paragraphs 28-33 infra, such conduct was illegal and cannot

confer a proprietary interest.

COMPLAINT FOR UNFAIR BUSINESS PRACTICES (BUSINESS AND PROF. CODES § 17200 AND FOR INJUNCTIVE AND DECLARATORY RELIEF - 11 COMMON SENSE JANUARY/FEBRUARY 20221

OUR PATIENTS, OUR SPECIALTY: AAEM VERSUS ENVISION

50.

1 2

Whether or not enforced by Envision, the inclusion of void non-competition

provisions in the agreement is a violation of § 16600 and an unfair business practice. 51.

Defendants actively conceal their unlawful agreements and business practices. To

prevent the detection of its scheme, Defendants employ nondisclosure agreements and provisions

and call their affiliates names other than Envision to avoid detection.

FIRST CAUSE OF ACTION

(Unfair Competition in Violation of Cal. Bus. & Prof Code § 17200- Injunctive Relief Against All Defendants)

9 10 11

52.

Plaintiff realleges and incorporates by reference each allegation as if fully stated

53.

Defendants transact business by operating controlled Physician Groups and

herein.

12 13

CAUSES OF ACTIONS.

Management Services Company as described herein.

54.

The violations of law described in this Complaint have been, and are being, carried

out and directed wholly or in part within the County of Contra Costa and other locations within

the State of California where Envision does business.

55.

California Business and Professions Code § 17200 prohibits any "unlawful, unfair

or fraudulent business practices." As alleged throughout this Complaint, Defendants' acts and

business practices, outlined in this first amended Complaint, constitute unfair business practices

because they offend established public policy and cause harm that greatly outweighs any benefits

associated with those acts and practices.

22 23

56.

The public and others were likely to be deceived by Defendants' acts, business

practices, and conduct alleged in this Complaint.

57.

Defendants have engaged within the last four years and continue to engage in

unlawful, unfair and/or fraudulent business acts or practices in violation of Section 17200. Such

acts and practices include, but are not limited to, the following:

27 28

COMPLAINT FOR UNFAIR BUSINESS PRACTICES (BUSINESS AND PROF. CODES § 17200 AND FOR INJUNCTIVE AND DECLARATORY RELIEF - 12 64

COMMON SENSE JANUARY/FEBRUARY 2022

OUR PATIENTS, OUR SPECIALTY: AAEM VERSUS ENVISION

•

Unlawfully engaging in and aiding and abetting the unlawful Corporate

Practice of Medicine within the State of California in violation of

Business & Professions Code 24000, 2502 et al. •

Unlawfully offering or paying consideration for the acquisition or

retention of emergency department exclusive contracts, and/or aiding

and abetting in the same, in violation of Penal Code § 650 and Welfare

and Institutions code § 14107.2 and attempting to do the same. •

Unlawfully restraining the practice of medicine by requiring physicians to execute illegal restrictive covenants to restrict their employment.

•

Deceiving the public and potential patients by representing that

Envision Physician Services was a physician group lawfully structured

and able to provide medical services to patients in violation of Business

& Professions Code § 17500.

14 15 16

58.

As a direct and proximate result of the preceding acts and practices, Defendants

have received income, profits, and other benefits they would not have obtained if they had not. 59.

By engaging in a pattern and practice of violating section 17200 as described

herein, defendants were able to unfairly compete with other entities such as Plaintiff's who are

engaged in providing administrative services to physician groups in the State of California

engaged in the violations of § 17200 and law described in this Complaint.

60.

Plaintiff is informed and believes, and based upon such information and belief,

alleges that as a direct result of these acts and omissions, Defendants have received or will receive

income and other benefits which they would not have received if they had not engaged in the

violations of Business and Professions Code § 17200 et seq. described in this Complaint.

61.

Plaintiff as providers of practice management services to Physicians without

committing the unlawful, unfair, and fraudulent business practices routinely employed by

Defendants have suffered an injury in fact and has and will lose revenue as it did, for example,

when Envision acquired the Emergency Department exclusive contract at Placentia-Linda

Hospital, which loss resulted in Plaintiff's losing its Management Services Agreement with PLEP,

COMPLAINT FOR UNFAIR BUSINESS PRACTICES (BUSINESS AND PROF. CODES § 17200 AND FOR INJUNCTIVE AND DECLARATORY RELIEF - 13 COMMON SENSE JANUARY/FEBRUARY 20221

OUR PATIENTS, OUR SPECIALTY: AAEM VERSUS ENVISION

to provide practice management services, and forced to compete at a disadvantage against

Defendants as a result of Defendants practices by Plaintiff’s following the law. 62.

Plaintiffs have no adequate remedy at law in that damages are insufficient to

protect the Plaintiff and public from the harm caused by the conditions described in this

Complaint.

63.

Unless injunctive relief is granted to enjoin Defendants' unlawful, unfair and/or

fraudulent practices, Plaintiff and the public will suffer irreparable injury. 64.

WHEREFORE, Plaintiff prays for the relief requested below;

SECOND CAUSE OF ACTION

(Declaratory Relief)

11 12 13 14 15

65.

Plaintiff realleges and incorporates by reference each allegation as if fully stated

66.

Defendants caused their controlled medical groups to enter into, implement, and

herein. enforce express agreements that are unlawful and void under § 16600. 67.

Envision through itself and its controlled medical groups offered to and/or paid

consideration to induce the granting of exclusive contracts/referral of patients in violation of Penal

Code 650 and Welfare & Inst. Code § 14107.02.

68.

Envision through itself and by the direct control of its controlled medical groups,

kickbacks, restrictive covenants, and other practices alleged violated California's ban on the

corporate practice of medicine in violation, among other things, of Cal. Bus. & Prof. Code §§2400

& 2502.

69.

Envision's the inclusion of restrictive covenants in their controlled medical group's

employment agreements with physicians have the purpose and effect of (a) reducing the open

competition among medical groups for emergency room staffing contracts; (b) reducing physician

mobility; (c) eliminating for physicians to pursue the lawful employment of their choice; and (d)

limiting physician choices for management and administrative service contractors.

27 28

70.

Envision's inclusion of restrictive covenants in their controlled medical group's

employment agreements is void and unlawful in that they are contrary to California's legislative

COMPLAINT FOR UNFAIR BUSINESS PRACTICES (BUSINESS AND PROF. CODES § 17200 AND FOR INJUNCTIVE AND DECLARATORY RELIEF - 14 66

COMMON SENSE JANUARY/FEBRUARY 2022

OUR PATIENTS, OUR SPECIALTY: AAEM VERSUS ENVISION

1 2 3 4 5 6

policy in favor of open competition and employee mobility. 71.

Envision's inclusion of restrictive covenants in their controlled medical group's

employment agreements is not limited to the protection of any proprietary interest of Envision. 72.

Envision's inclusion of restrictive covenants in their controlled medical group's

employment agreements does not fall into any statutory exception to § 16600. 73.

Envision's model and control over its physicians and its subsidiary physician

groups constitute the practice of medicine by an unlicensed entity in violation of Business and

Prof Code § 2400.

74.

Envision has used its control over its controlled medical groups offered to and/or

paid consideration to induce the granting of exclusive contracts/referral of patients in violation of

Penal Code 650 and Welfare & Inst. Code § 14107.02.

75.

Plaintiffs empower local, independent, democratic emergency physician groups to

meet their full potential. Their member groups practice in a fair and transparent setting where

each physician is an owner. Plaintiffs’ member groups retain full ownership of their practices.

Plaintiffs’ member groups compete directly with Envision-controlled groups for exclusive

emergency department referral agreements.

76.

A present case and controversy exist regarding Envisions current practices of

violating the ban on the corporate practice of medicine, using restrictive covenants, and offering

remuneration in exchange for patient referrals. Private equity-owned Envision, through its lay

management, shuts out legally operating medical groups, such as those partnering with Plaintiff,

by offering remuneration to hospitals in exchange for emergency referral contracts at Hospital's

previously serviced by AAEMPG partnered medical groups, including at Placentia-Linda

Hospital, then illegally shuts out the future competition by requiring all physicians practicing

medicine in the emergency department to sign restrictive covenants preventing them from

working for a competing group or removing Envision's control over the controlled group.

77.

Plaintiffs are informed and believe that Envision is actively marketing its services

to other Emergency departments throughout California and, in so doing, will continue its

corporate practice of medicine, offers of remuneration in exchange for patient referrals, and

COMPLAINT FOR UNFAIR BUSINESS PRACTICES (BUSINESS AND PROF. CODES § 17200 AND FOR INJUNCTIVE AND DECLARATORY RELIEF - 15 COMMON SENSE JANUARY/FEBRUARY 20221

OUR PATIENTS, OUR SPECIALTY: AAEM VERSUS ENVISION

restrict emergency physicians from working for competing medical groups. Envision will

continue these practices in its current hospital contracts and will expand them to new hospitals

unless a judgment declares such practices illegal.

4 5 6 7 8 9 10

78.

Declaration that Envisions’ restrictive covenants are void and may not be used in

agreements with physicians; 79.

Declaration that Envisions’ creation or control over its controlled medical groups

as described herein constitutes the corporate practice of medicine and is therefore unlawful. 80.

Declaration that Envisions offers of remuneration in exchange for exclusive

emergency department referral agreements, as described herein, constitute illegal kickbacks. 81.

WHEREFORE, Plaintiff prays for the relief requested. VI.

11 12

WHEREFORE, Plaintiff prays for:

PRAYER.

Defendants be enjoined engaging in acts constituting the practice of medicine

through the means and methods described herein, including but not limited to creating controlled

medical groups, exercising control over billing, staffing, and related services, use of restrictive

covenants, or using control using its control over controlled medical groups to require those

groups to include restrictive covenants in their employment and independent contractor

agreements with any California physician, otherwise aiding and abetting in the Corporate Practice

of Medicine.

Defendants be enjoined from offering or providing remuneration or anything of

value to any Hospital or Hospital system operating in the State of California, including hospital

services below-cost or market in exchange for patient referrals.

A declaration that Defendants practice of causing their controlled medical groups

to enter into, implement, and enforce restrictive covenants similar to those identified in paragraph

45 above is unlawful and that the restrictive covenants are void under Cal. Bus. and Prof. Code

§§16600.

A declaration that Defendants practice of offering to or agreeing to provide

Hospitals with personnel to staff departments without the requirement of a subsidy (where

COMPLAINT FOR UNFAIR BUSINESS PRACTICES (BUSINESS AND PROF. CODES § 17200 AND FOR INJUNCTIVE AND DECLARATORY RELIEF - 16 68

COMMON SENSE JANUARY/FEBRUARY 2022

OUR PATIENTS, OUR SPECIALTY: AAEM VERSUS ENVISION

subsidies are paid) in exchange for E.D. contracts constitute violations of Penal Code 650,

Welfare & Inst. Code § 14107.02.

A declaration that Defendant's control over its controlled medical groups

constitutes the corporate practice of medicine in violation of, among other things, of Cal. Bus. &

Prof. Code §§2400 & 2502.

6 7 8

Attorney's Fees as allowed by law, including but not limited to those allowable

under Cal. Code Civ. Proc. § 1021.5. 8.

For such other and further relief as the Court may deem proper.

9 10

Date: December 20, 2021

MILLSTEIN & ASSOCIATES

11 12 13 14 15 16 17

By:_________________________ David J. Millstein, Esq. Gerald S. Richelson, Esq. Attorneys for PLAINTIFF AMERICAN ACADEMY OF EMERGENCY MEDICINE PHYSICIAN GROUP, INC.

18 19 20 21 22 23 24 25 26 27 28

COMPLAINT FOR UNFAIR BUSINESS PRACTICES (BUSINESS AND PROF. CODES § 17200 AND FOR INJUNCTIVE AND DECLARATORY RELIEF - 17 COMMON SENSE JANUARY/FEBRUARY 20221

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.

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.

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.

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.

Direct all inquiries to: www.aaem.org/membership/benefits/job-bank or email info@aaem.org.

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 None Available at this time.

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.)

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)

LOUISIANA

Emergency Medicine Physicians The Department of Emergency Medicine at Ochsner Medical Center in New Orleans, Louisiana is a well-established department that sees 75,000+ visits/year as a tertiary referral center for the larger Ochsner Health System. The department welcomed its first class of Emergency Medicine Residents in 2020 and also has seen continued rapid growth in the clinical enterprise. The department is in search of American Board of Emergency Medicine or American Osteopathic Board of Emergency Medicine certified/eligible physicians, preferably with fellowship/additional niche training, who can further grow the diversity of excellence within the academic department. Interested applicants should send Cover Letter / Curriculum Vitae to the Department Chair, Nicole McCoin, MD, at nicole. mccoin@ochsner.org. (PA 1863) Email: morgan.aymond@ochsner.org Website: https://ochsner.wd1.myworkdayjobs.com/en-US/ OchsnerPhysician/job/New-Orleans---New-Orleans-Region--Louisiana/Physician--Emergency-Medicine--All-Regions_ REQ_00022121

COMMON SENSE SEPTEMBER/OCTOBER 2021

NEW JERSEY

The Department of Emergency Medicine at Rutgers New Jersey Medical School is recruiting a board-certified emergency physician and medical toxicologist as Director of our Medical Toxicology Fellowship. The fully-accredited training program is integrated with both our inpatient and outpatient consultation services as well our Poison Control Center. We are committed to developing a diverse faculty. Applicants should have a desire for advancing clinical, educational, academic, and administrative excellence. The ideal candidate is committed to engaging in opportunities for scholarship and collaboration. Three years or more as a core faculty member in an ACGME-accredited medical toxicology program is required. (PA 1869) Email: rosanian@njms.rutgers.edu Website: https://njms.rutgers.edu/departments/emergency_ medicine/

NEW JERSEY

The Department of Emergency Medicine at Rutgers New Jersey Medical School is actively recruiting talented Emergency Physicians interested in clinical education and professional growth opportunities. We are home to an enthusiastic and diverse group of emergency physicians who are committed to education, scholarship, research, service, and outstanding clinical care. We are committed to fostering a diverse and inclusive faculty. Applicants should have a desire for clinical, educational, or academic advancement. The ideal candidate is committed to engaging in the numerous opportunities for professional development that the department and institution offer, while sharing our commitment to inclusive excellence. (PA 1870) Email: rosanian@njms.rutgers.edu Website: https://njms.rutgers.edu/departments/emergency_ medicine/

NORTH CAROLINA

Wake Forest Emergency Providers is currently seeking to add to our team of exceptional patient-centered emergency physicians due to expansion and growth resulting from our joining together with Atrium Health as a single enterprise. Opportunities exist in Central/Western NC, as well as Charlotte, NC, beginning as early as November 2021. We are open to experienced emergency medicine residency trained physicians as well as recent graduates for these positions. Wake Forest Emergency Providers offers a unique employment model inclusive of comprehensive benefits, local influence on practice decisions, and a strong provider voice in care delivery. (PA 1866) Email: michael.ginsberg@wakehealth.edu Website: http://www.wakehealth.edu

NORTH CAROLINA

Wake Forest School of Medicine’s Department of Emergency Medicine has a rare opportunity to join our academic faculty team as an Assistant or Associate Professor in a position with a scholarly focus on Emergency Medicine Diversity, Equity, and Inclusion. This position will be an integral part of our ongoing EM departmental diversity and inclusion initiatives and the successful candidate will take over leadership of our active DEI committee. There are additional opportunities to participate and lead new and ongoing initiatives that will impact patient care in our local community and throughout our learning healthcare system with Atrium Health. (PA 1867) Email: michael.ginsberg@wakehealth.edu Website: http://www.wakehealth.edu

SECTION III: POSITIONS NOT RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK ADVERTISING CRITERIA (Below are military/government employed positions.) None Available at this time.

SECTION IV: POSITIONS NOT RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK ADVERTISING CRITERIA (Below are independent contractor positions.)

CALIFORNIA

PHYSICIAN - PEDIATRIC ORTHOPAEDIC URGENT CARE CENTER (Los Angeles) SUMMARY: Under the general supervision of the Urgent Care Medical Director, coordinates and delivers the care of pediatric patients in the outpatient and the urgent care settings managing acute, chronic, surgical and congenital musculoskeletal conditions. The Physician is responsible for providing musculoskeletal care in the urgent care setting, including fracture treatment. REQUIRED QUALIFICATIONS: • Graduated from an accredited medical school and residency program AND have a current unrestricted valid license to practice medicine in the State of California, including DEA license. • Fluoroscopy X-Ray Supervisor and Operator Certificate, issued by the California Department of Public Health. • Must be comfortable seeing pediatric patients who are between the ages of 2 and 18 years of age. •ACLS/ PALS certified (PA 1872) Email: mrpeters@mednet.ucla.edu Website: https://workforcenow.adp.com/mascsr/default/mdf/ recruitment/recruitment.html?cid=1fe50326-beac-4a7c-a564-f8 a14f9c5bb0&ccId=19000101_000001&jobId=412173&lang= en_US&source=CC4

COMMON SENSE JANUARY/FEBRUARY 20221

COMMONSENSE

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AAEM-PG Files Suit Against Envision Healthcare Alleging the Illegal Corporate Practice of Medicine Read the Lawsuit to Learn How We Champion the Emergency Physician. bit.ly/aaempglawsuit

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