The Pulse Spring 2023

IMPROVING MEMBER SUPPORT

RESTORING THE VALUES OF THE PAST

EDITORIAL STAFF

Timothy Cheslock, DO, FACOEP, Editor

Victoria Selley, DO, FACOEP, Assistant Editor Mary Kate de Leon, Marketing & Communications

TABLE OF CONTENTS

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ACOEP is a registered trademark of the American College of Osteopathic Emergency Physicians.

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PRESIDENT’S REPORT

Timothy Cheslock DO, FACOEP

THE ON-DECK CIRCLE

Brandon Lewis, DO, MBA, FACOEP, FACEP

EXECUTIVE DIRECTOR’S DESK

DeAnna McNett, CAE

EMS COMMITTEE UPDATE

Rose Anna Roantree, DO, FACOEP-D

RSO UPDATE

Spencer Sage Heath, OMS-4, RSO Board Vice President

LAUREL ROAD PARTNERSHIP

WELLNESS COMMITTEE UPDATE

John Dery, DO, FACOEP, FACEP, FAWM

ACOEP PRACTICE ADVOCACY

Jeremy Selley, DO, FACOEP

IMPACT OF NP’S AND PA’S

Andrew W Phillips, MD, MEd and Gregory Wanner, DO, PA

SPRING SEMINAR FOLLOW UP

WHAT WOULD YOU DO? ETHICS IN EMERGENCY MEDICINE

Bernard Heilicser, DO, MS, FACOEP-D, FACEP

Cover Photo by: Grace D. Jones D.O. from Washington University School of Medicine, taken during the Spring Seminar

As I write this article, the results of the 2023 Match have just been released and the internet is flooded with tweets and comments, opinions of many varieties as to what is happening to our profession. What went wrong? Why so many unmatched slots? Is EM no longer appealing to medical students? I do not profess to have the answers to all these questions and the opinions I express here are truly my own. Where does the future of our profession lie?

One of the foremost issues we need to confront head on is what is our current state? Based on conversations with EM physicians all over the country it’s clear that our state of affairs is not good. Many departments are functioning out of a physical space severely restricted by boarding patients, are chronically understaffed by nursing, and lack the resources to deal with the daily deluge of patients redirected from primary care offices, urgent cares, and other settings where the on-site providers just don’t feel comfortable addressing what may or may not be a more complex problem. Hospitals were not prepared to deal with the issues that led us to our current state and either chose not to or have deflected in many instances back to us as to how we are going to fix the situation and still meet metrics that were designed for a fully operational department that

THE FUTURE OF OUR PROFESSION

is adequately staffed. Many of the problems we deal with are the result of the hospital failing to do its part to mitigate the situation due to cost or inconvenience. Regardless, it is our current work environment in many instances. Does this appeal to you? Now to be fair it is not like that everywhere. In many cases it’s better, in some cases even worse. Either way, the work environment has deteriorated for most of us to some degree over the last few years. The pandemic has forever changed the landscape of medicine. Many practices outside of EM have seemed to go entirely virtual. Sometimes coming to the ED is the only way patients get true human interaction and touch.

Selling the profession to a future generation of physicians within the confines of that landscape is challenging. It is not something you can hide either. Students see it as

they rotate through our departments. They are very astute in picking up on the frustrations in a department. Hopefully they are still able to garner educational value and pearls to take forward in their education, because even in harsh environments, learning can take place. Some students thrive in a challenging environment and those are the ones that we seek to match and we have! Over 2500 successful matches for EM took place this year.

What about the match itself? Are there inherent problems with the software, the algorithm? Are programs or students changing they way they submit their lists? These are great questions that have come up, but ones that I cannot shed any light on. It would be interesting to conduct a study and see if any of that had a bearing on the results. Are communications during interviews between students and

PRESIDENT’S REPORT

Timothy Cheslock, DO, FACOEP

...THE ONLY WAY TO MAKE OUR SPECIALTY BETTER IS TO BE PART OF THE SOLUTION!”

faculty leading one or the other to rank a certain way and is that hurting prospective matches?

Barring a functional issue with the match, why is it that certain programs filled and others have not? Scanning the list it is hard to draw any definitive conclusions. Many well-established programs did not fill, many newer programs did not fill. It’s all over the map. I’m sure in the coming months feedback from these programs as to what their individual circumstances may have been will be sought out. How much of that you and I will be privy to remains to be seen. Most programs find it gut wrenching enough to look introspectively. I don’t know many that will share their pain in public forums.

The number of new residencies has most definitely played a role in our current situation. Over the last few years there has been an explosion of new programs. Many concentrated in my own state of FL but also in many other areas of the country. What brought about this rapid proliferation continues to be up for debate. Many of these programs have come under the umbrella of one or two large healthcare institutions. Was this a strategic move sparked by a tremendous desire to educate or

some other factor that prompted the plunge into the GME environment? As it stands currently, the ACGME standards for opening a new program are fairly obtainable for even the most basic community hospital settings. Can you blame systems for taking advantage of it for their own gains? What can be done about it in the future?

By now you are thinking where is the good in all this? Is there any? Of course there is, if not we would all just throw our hands up and walk away. We have a growing and dynamic specialty. Until now we have benefited from a highly sought after profession with tremendous opportunity. Have we saturated the market? Hardly. Not a day goes by that I receive offers of employment from across the country. Could our profession use some fine tuning? Absolutely.

Emergency Medicine is full of dedicated, well-trained professionals. We are in a fairly well compensated specialty that affords us a lifestyle that many would be envious to have. It is challenging and stressful, but at the end of the day we do our best to care for those that are in need. Nothing is more satisfying than a thank you from a patient who truly appreciated your

care or better yet asks where is your office, can you be my doctor all the time?

As the president of our college, I can assure you that the board is keenly aware of all the issues I mention above and many more. We are active in collaborating with other national EM organizations to assure that your concerns are addressed. We advocate everyday to help strengthen the profession and make it the best it can be. Over the next several months myself and many other members of the board will be participating as your representatives at collaborative meetings on these topics. We have been invited by ACGME to send representatives to discuss new basic standards for EM residency training. I will be attending the EDPMA meeting along with the president of ACEP to address their organization and the challenges we all face. We are here for you and pledge to continue to represent your concerns for our specialty and our patients. The only way to make our specialty better is to be part of the solution. I invite each of you to do your part so that we can once again make Emergency Medicine the great professional we all devoted ourselves to when we made our own match! –•–

In the previous decade, the increasing inability for Emergency Medicine groups to come to agreement on reasonable compensation with payers who continued to ratchet down on physician reimbursement led to an increasing number of patients who found themselves being taken care of by a physician who was not in network with their insurance plan. This was compounded by some physician groups who, as ‘bad actors’ took advantage of the lack of guidelines to purposely bill patients “out of network” to raise their revenue. As a result, an increasing number of patients found themselves getting caught by the “surprise coverage gap” as it was referred to by physicians or a “surprise bill” as named by the insurance industry.

As the problem continued to grow, all parties involved; physicians, payers, and patients, advocated for the government to step in and help take the patients out of the middle of these disputes. After much debate and wrestling in the halls of Congress, the “No Surprises Act” was passed in 2020. While it was not hailed as a “good” bill by hospitals and physicians, it was not a terrible bill. Much of the language that heavily empowered insurance companies to abuse the new rules were written out of

SURPRISES FOUND WITHIN THE “NO SURPRISES ACT”

the final bill. As passed, the bill’s general construction deemed that if a patient was seen by an “out of network” physician, the physician would submit a bill to the insurance company. The insurance company would then submit a “Qualifying Payment Amount” (QPA). This is supposed to be based on the “median in-network rate” for that insurance company. If the physician feels this is unreasonably low, they can appeal to an authority for Independent Dispute Resolution (IDR). An arbiter then receives a proposed payment amount from the insurance company and one from the physician and has to pick one of the two to resolve the issue.

Unfortunately, after a bill is passed, it goes to the executive branch for “rule writing” and in this case, the current administration wrote the rules to re-incorporate many

bad provisions that Emergency Physicians protested and in direct contravention to the actual bill’s language!! For example, the rules require the arbiter to heavily weight the QPA as an “appropriate amount” for payment. There were also changes (relaxation) of the guidance around how an insurance company determines the QPA.

So what was the result?

As you might expect, insurance companies have used the opportunity to drastically cut payments to physicians. For example, since a QPA has to represent the “median” of the in-network region, the insurance company will often unilaterally cancel contracts with physician groups with the better paying contracts. This then results in the “median” for the region being lower (having removed the higher end contracts). They can then continue this trend,

AS A RESULT, THE “FRONT-LINE HEROES” OF COVID ARE NOW BEING FACED WITH THE CHOICE TO ACCEPT LOWER PAY OR LEAVE THE CONTRACT WITH THEIR HOSPITAL.. .”

wash and repeat continually lowering the regional median. Also, there are no rules around what defines a “region”. As a result, like political parties, the insurance companies create “gerrymandered” regions so they can include as many low paying contracts and as few high paying contracts in a QPA calculation! In some cases this has led to insurance companies submitting QPAs that are less than Medicare!!

So as a physician, if you have a contract with an insurance company that pays you 200% of medicare reimbursement for your insured patients, you might have the insurance company come to you and say they want you to take a 25% cut in your reimbursement (down to 150% of medicare). If you say no, they will term you and you will be considered “out of network” and they will pay you only the QPA that they solely determine and could be less than Medicare!

Either way, the physicians see lower reimbursement. When making your decision, it would be nice to know what that QPA that you would receive, right? The bill requires they disclose this to you, however, thus far, many insurance companies have failed to disclose this information! This is only the tip of the iceberg in terms of the tricks insurance companies have used to cheat physicians from fair reimbursement and patients from having good access to care in order to boost their profits to record levels.

Currently, several physician and hospital groups have filed lawsuits around the NSA. In a few cases, a federal judge has ruled against the administration, staying the implementation, and requiring the rules be re-written. While this may portent improvement down the road, these delays only serve the insurance companies as they can continue their bad

behavior to artificially lower their median payment amounts knowing that the IDR process is being log-jammed and they will not have to make appropriate payments until such time as there are revisions made. In the meantime, physician practices suffer with significant cuts in their reimbursement. As a result, the “front-line heroes” of COVID are now being faced with the choice to accept lower pay or leave the contract with their hospital meaning that patients are having decreased access to quality physicians.

ACOEP will continue monitoring the changes around the NSA and working collaboratively with other EM organizations to advocate and meaningful reform that treats Emergency Physicians fairly. Please continue to support our organization and to get involved with advocacy at the with your local legislators. –•–

more details coming soon!

As many of you know ACOEP is under new management. In January of this year Affinity Strategies took over association management duties. Their first project before even signing the contract was to hire and have the Board approve a new Executive Director. I am grateful to have been chosen as the new Executive Director for ACOEP. With the direction of the ACOEP Board and support from Affinity I hope to increase collaboration between ACOEP and other EM orgs significantly. I want to thank all of you for the warm welcome I have received since I came to ACOEP, especially at the recent Spring Seminar meeting. Coming back to Emergency Medicine through ACOEP has honestly felt like coming home again.

With the direction of your Board of Directors I have made my first mission for the organization to review and update all your member benefits and make those benefits transparent and known to you. I want to make sure you are receiving value for your ACOEP membership dues. The first item on my list that I will focus on in this issue is the Resident Education Membership program to address the significant drop in membership numbers from our Student to Resident memberships. I want to introduce you to our newly updated Resident Education Membership that is available for residency programs to sign up

DeAnna McNett, CAE Executive Director

NEW MANAGEMENT, NEW SUPPORT

their residents. At $165 a year per resident, we feel this is a value for your program. Now I know our program directors are wondering, exactly what does that $165 get me?

RESIDENT MEMBERSHIP

• Your resident receives access to the HIPPO EM Board Review Resident Package (normally $249)

• A subscription to WestJEM, included is the waiver of submission fees for ACOEP sponsored publications

• Access to the ACOEP Digital Classroom with 100’s of hours of educational content

• FOEM and RSO opportunities (discussed below)

• Multiple opportunities for publication in ACOEP, RSO and WestJEM publications.

I also want to announce a new program I am creating called the ACOEP 100 Club that will be available to Residency Programs that have 100% membership of their residents in ACOEP.

Those programs will receive additional membership perks like:

• 50% off ACOEP Membership and Scientific Assembly registration fees for the Program Director.

• A 50% discount on submission fees for the CPC Competition.

• Waived submission fees for 1 submission to each of the other 5 competitions.

• Unlimited use of the Digital Classrooms educational recordings for your entire program.

• Access to the FOEM Research Network for your residents and CORE Faculty

• A 1-thousand-word promo article for your program in our The Pulse & Fastrack publications annually Also, your residents will automatically receive membership in the RSO.

Among other benefits RSO membership offers, Leadership opportunities for your residents through its congress, committee, and Board of Directors opportunities.

One item to note – If your program has even ONE ACOEP member you can nominate a resident (ACOEP member) to serve as the Program Representative to the RSO congress. This rep would be the point person between you and the ACOEP/RSO. They will receive a voting seat in the congress and information throughout the year on activities, publications and competitions as well as other information that needs to be communicated to your program.

EXECUTIVE DIRECTOR’S DESK

To offset some of the costs for your resident to attend the RSO congress held at our Fall Scientific Assembly, the RSO provides a $300 travel stipend.

I am looking for ways to increase value to ALL our categories of membership. Additionally, I am looking for feedback from you! There is a QR code below to access surveys I have created to receive feedback from our membership on our benefits and offerings. Please complete those surveys and let me know your ideas to increase value to your membership. Also, I am always listening, there is an additional survey to let me know about anything within ACOEP you feel needs changed, improved or just commented on. I am also available by email anytime to address any additional needs at:

deanna@affinity-strategies.com

As a reminder, please save the date for our next in-person event!

2023 Scientific Assembly

August 11 (pre-day) – 15, 2023

Washington Hilton

Washington, DC

More information on the Scientific Assembly will be updated on the website in May!

Sincerely,

DeAnna McNett, CAE ACOEP Executive Director

ACOEP DOCMATTER COMMUNITY

The ACOEP family has a great place to collaborate and learn. We want to encourage the use of the ACOEP DocMatter Community. The platform, accessible only to ACOEP members, is designed to harness the global connectivity of the internet and make it easier than ever to broaden peer learning.

Join a discussion or start one of your own. Recent topics of conversation have included new COVID-19 infections in fully vaccinated healthcare workers and compensation for frontline workers. The Pulse column “What Would You Do? Ethics in Emergency Medicine” from Bernard Heilicser, DO, MS, FACEP, FACOEP-D will also now be featured in the DocMatter Community. Log in and tell us how you would handle this issue’s dilemma.

To access the Community please visit DocMatter.com/ACOEP.

EMS COMMITTEE UPDATE

The EMS Committee has been busy! We are awaiting further information on when the AOBEM EMS subspecialty exam will be offered and have discussed and compiled study resources so that those who take the exam will be prepared. Dr. Beirne has been instrumental in this process.

We also held the first Loeb Legacy Dinner, in memory of friend and colleague Kevin Loeb, a longtime EMS committee member committed to the mentorship of medical students interested in the field of EMS, at the Scientific Assembly in Las Vegas, on October 24. It was well-attended by medical students at the conference. We hope to continue funding this in the future through directed donations to FOEM.

Our committee members continue to represent us and our interests at national meetings of ACEP’s EMS committee, the National Association of EMS Physicians (NAEMSP), the Prehospital Guidelines Committee, the National Registry of Emergency Medical Technicians (NREMT), and the Commission on Accreditation for Prehospital Continuing Education (CAPCE).

We hope to present an EMS lecture track at the Scientific Assembly in Washington, DC. If you have any ideas for topics you would like to see covered, please let us know! –•–

RSO BOARD UPDATE

The Resident and Student branch of ACOEP is proud to continue our legacy of offering ongoing support, networking, and educational opportunities to our membership across the continuum of learning. Recent efforts include:

• Continuation of our popular Resident Lecture Series, which connects our resident members with lectures on high-yield topics such as financial literacy, personal growth, and clinical pearls.

• Cultivation of authentic mentoring opportunities with our student members, as meaningful mentorship was often identified as an area where students felt we had room to grow. We’re excited to debut our Red Flag Mentorship series, where successfully Matched residents with perceived application deficits will be paired with small groups of students who share personal concerns regarding those same application areas.

• Curation of best-in-class speakers and workshops for the RSO portion of ACOEP Scientific Assembly 2023, taking place in Washington, DC, Aug 12-13. The RSO schedule is shaping up to be packed with exciting activities for all members in attendance (including an exciting and innovative escape room experience for our Leadership Academy attendees). Those who braved our Hot Sauce Airway Extravaganza in Phoenix this Spring know that we don’t shy away from challenges. We can’t wait to share what we’ve been working on!

In summary: we on the ACOEP-RSO board thank our members for their continued support, and we look forward to seeing you all soon! –•–

ACOEP EMS COMMITTEE Rose Anna Roantree, DO, FACOEP Chair

ACOEP RSO BOARD Spencer Sage Heath, OMS-4 Vice President

WELLNESS COMMITTEE UPDATE

NURTURING FINANCIAL WELL-BEING WITH THE 529 COLLEGE SAVINGS PLAN

Wellness is a very generic term that can mean so much, in so many different ways, to so many different people. This month, let’s take a few moments to focus on a small aspect of our FINANCIAL WELL-BEING.

As a long time Boy Scout (yes, that is me heading off to my first summer camp; love those 1980s socks) I can appreciate how the Scout Motto “Be Prepared” has often helped (if not saved) my career in the Emergency Medicine. Having a backup ET Tube 1 size smaller then expected out and ready to go for that difficult airway, keeping an extra 18g needle in my coat pocket for the tension pneumothorax in the vented ICU patient, etc. As I reach

the next phase of parenting and guiding my now 17-year-old son on his path to higher education, navigating the myriad of college pamphlets arriving daily in our mail, and starting to apply for scholarships; I am thankful for that lifelong motto once again. Specifically, I am thankful for my “SCOTT”.

Unlike most things in modern medicine, SCOTT is not a fancy acronym for the latest and greatest medications or trials published in the academic journals. Scott is the financial planner that I met early in my internship who helped me plan out my financial future. It wasn’t too long ago (17 years and 9 months to be precise) I found out I was going to be a father (while I was busy learning how to correctly treat a potassium of 3.3 and sweating the safety and ethics of a nursing asking me to order more then 2mg of morphine at a time for a chest pain patient) that Scott was busy too. Scott had his hands full teaching me about managing the money that I was making as a resident, that I would be making as a future attending, and would need to have that money working for me in my distant future and retirement. As a freshly minted intern, I realized I had NO idea how to plan for any of this.

“Do you want your son to go to college some day?” Of course, I did, who wouldn’t want to support their children’s dreams of becoming anything they want to be (anything other than a doctor!)

That’s when Scott introduced me to a 529 College Savings Plan.

Each state offers a 529 savings plan through an investment organization such as TIAA, Vanguard, or USAA. Contributions are made to the plan on an after-tax basis; investment earnings grow tax-deferred and distributions for qualified expenses are tax-free. SOME states with an income tax provide a tax deduction for contributions.

I made the most of this program. By maxing out my contributions every year, I not only reduced my total taxable income and saved money on taxes, I was saving my son money for his future. In fact, his 529 has outpaced several of my own investments and he will have over $100,000 saved for college. Just when I thought I had finally understood everything, Murphy and his inevitable law struck me square in the face; I was blessed with my daughter. Since I had the wise advice from Scott to open a 529 for my son, it only made sense to start one for my daughter as well…and that is when I learned the follow up lesson about 529 plans: TIME. While I made the same contributions to my daughter’s account as I did my son’s, I started saving for her earlier. Thus, I had more time to take advantage of its’ awesome compounding power. While the state tax deductions are a nice benefit, the true power of 529 plans is many years of compounded investment earnings withdrawn tax-free.

THE BIG LESSON

The big lesson: Open an account as soon as your child has a social security number! Is a 529 plan right for you? Like anything, there are pluses and minuses. Many 529 plans have low maintenance and investments costs, high contributions limits (especially for high earners), and have very little impact on financial aid. That said, some states will not offer a tax deduction, and most will charge penalties if the earnings and/or contributions are withdrawn for something other then qualified college expenses. But don’t take my word for it. There are several websites you can easily access to get your state specific information, for example:

• Nerdwallet.com: nerdwallet.com/article/investing/529-plans-by-state

• Collegesavings.org: collegesavings.org/find-my-state-529-plan/

• The Best 529 Plans of 2022 - Forbes Advisor: forbes.com/advisor/ student-loans/best-529-plans/

Oh, and if you find that your state doesn’t have the best plan or that another state offers lower management fees (this is why comparing plans saves you money!) you are not required to use the plan from the state you reside in! You are allowed to shop around and find the best one and use another state’s plan.

With the help of Scott, Lord Baden-Powell’s “Be Prepared” Motto, and my handy 529 plan, a large chunk of college tuition is all set. Now he just has to figure out if he wants to attend Michigan, Michigan State, or MIT (and I do hope he meant MichiganInstitute of Truck Driving when he said that!)

Until next time, choose to be well. –•–

John Dery, DO, FACOEP, is a proud father of two (hopefully) college bound children and member of the Wellness Committee (and definitely NOT a financial planner). Thanks to “Scott D” for being the inspiration and reason i can write this with a smile on my face. This article should be used for educational purposes and is not considered professional financial planning advice.

…I’M LOOKING FORWARD TO THE FUTURE AND FEELING GRATEFUL FOR THE PAST. - MIKE ROWE”

Open an account as soon as your child has a social security number!

Jeremy Selley, DO, FACOEP, is a native of Nibley, Utah. He graduated from Utah State University with a B.S. and then went to Kirksville College of Osteopathic Medicine for his D.O. Jeremy met his wife, Victoria H. Selley, D.O., in medical school and they then attended Emergency Medicine Residency at Lehigh Valley Health Network. After residency, Dr. Selley served 4 years in the US Navy and was deployed on the 24th Marine Expeditionary Unit in 2012. In 2014, Dr. Selley joined USACS full time and has been with the company since. In 2018, Drs. Selley moved from NC to FL and started work with AdventHealth Sebring. Dr. Selley began working with Carolina Honduras Health Foundation in 2017 and serves on their Board of Directors. He travels to Honduras yearly to help treat patients. Dr Selley chairs the ACOEP Practice Advocacy Committee and works with Florida College of Emergency Physicians to increase advocacy awareness.

ACOEP PRACTICE ADVOCACY

By Jeremy Selley, DO, FACOEP

How many of us are looking forward to a “Pay Cut” in the next 2-3 years for the same level of productivity? If your answer is No, then please read on!

Advocacy is the “public support for or recommendation of a particular cause or policy.”

If you do not have the time to attend D.O. Day on The Hill, ACEP’s Leadership and Advocacy Conference, or state level activities like many of us, please be ready to GIVE a fraction of what could be a 5% to 15% pay cut to those who “ADVOCATE” for you! You might be surprised by what many physician advocacy groups do for you behind the scenes to protect our practice rights.

In 2018, the AOA stopped requiring AOBEM members to pay their AOA dues to maintain board certification. Although many of us argued we got no significant benefit from this, they do an enormous amount of osteopathic brand management and advocacy on your behalf. The advocacy arm, OPAC (osteopathic political action committee) cannot solicit your support if you are not an AOA member. Even if you continue to not pay your AOA dues, please consider supporting OPAC.

Why would I give a non-taxdeductible donation to a political

action committee when I don’t ever give money to politicians?

Advocacy begins with having a seat at the table. Although as citizens we all have a voice in our democratic system, contributing to a political action committee allows your voice to be expressed in a different way. Organizations like OPAC, NEMPAC, and FCEP use your contributions to share all of our voices collectively. They do that by supporting those elected officials and candidates for office who are willing to listen, and support legislation that will improve the practice of emergency medicine and the careers of emergency physicians. Contributions to a PAC provide an opportunity to meet with, and educate policymakers on the unique aspects of emergency medicine practice.

“I cannot commit $500 or $1000 for advocacy!” Even though most of us make a good living, it can cause anxiety to donate a large sum of money. Whether it is OPAC, NEMPAC, FCEP or similar, they all have a monthly option where you can choose $50-$100/month which you will never miss via your monthly credit card payment if you just commit now. This amount helps to maintain your current level of income, practice ability and defend the provider practice creep.

The AOA has a grassroots advocacy sign up on www. osteopathic.org and ACEP has a 911 Grassroots network as well. These grassroots email lists will give you notification to email your representatives when US House/Senate votes and issues occur and pre-populates the email with why we should either support or NOT support the legislation. This is a critically important step because you are a not only a physician, but

ADVOCACY IS THE PUBLIC SUPPORT FOR OR RECOMMENDATION OF A PARTICULAR CAUSE OR POLICY.”

a constituent. Although it may only be one email, if they get it from all of your coworkers as well, they begin to listen.

Jeffrey Davis (ACEP Director of Regulatory and External Affairs) puts out a weekly Regs & Eggs email newsletter that is very informative and explains in detail what the ACEP advocacy arm does for you. Recent items discussed include President Biden’s FY 2024 Budget, Federal Trade Commission considering

SUPPORT ADVOCACY

a Ban on Non-compete clauses, and No Surprises Act legal updates. These issues may seem trivial, but critical in the sense that they are all issues vital to our everyday practice and have drastic consequences if we don’t have someone to “Advocate” for us!

Where do I start? Donate. Read. Share. Scan the QR codes below to start!! –•–

College Savings Link

Andrew W Phillips, MD, MEd, FAAEM, is an Emergency Physician, Intensivist, and Founder and Editor-in-Chief at EM Coach, LLC. He graduated medical school from the University of Chicago Pritzker School of Medicine, and went on to do both an emergency medicine residency at the Stanford University/ Kaiser EM program and an anesthesia critical care fellowship at Stanford University.

IMPACT OF NP’S AND PA’S ON RESIDENT EDUCATION

By Andrew W Phillips, MD, MEd, FAAEM and Gregory Wanner, DO, PA

An article soon to be published in the Western Journal of Emergency Medicine provides the first quantifiable evidence that NPs and PAs in the emergency department are, on a whole, deleterious to EM physician resident education. Interestingly, multiple prior studies evaluated ED performance and non-physician practitioner (NPP) perspectives, and there is an existing best practices publication 1 , but there were no prior studies asking physician residents about the impact it had on them.

the most part, but [that] also means we miss out on some of the common lower acuity presentations and procedures” and “I’m expected to spend time educating NP/PA students to train my replacements.”

Fifty-seven percent of residents reported at least one procedure for their patient being performed by an NP or PA during an ED rotation, and 60% reported at least one such incident offservice.

Gregory Wanner, DO, PA, is an Emergency Physician & Academic Faculty with Christiana Care Health System. In 2021 he worked as Chief Physician with the Delaware division of public health, assisting with the school-based antigen testing program, COVID-19 topics, and response.

A national survey of American Academy of Emergency Medicine Resident & Student Association members yielded a 34% response rate with 393 responses, and post hoc analyses showed no nonresponse bias. Sixty-seven percent responded that NPPs in the ED detract or greatly detract from resident education, while 30% reported no impact. Only 3% reported enhancement to their education. Further concerning was that 33% were “not at all confident” that they could report concerns about NPPs to local leadership without fear of retribution, and 65% had no confidence the ACGME could satisfactorily address their concerns.

The narrative responses mirrored the Likert-type responses with comments including “[NPPs] see lower acuity patients for

A few positive comments were made, such as “NPPs frequently run fast track, which opens the opportunity to see sicker patients without being overloaded with lower acuity complaints” and “They have knowledge of the system when you’re starting out.” Also, “[NPPs] cover the ED during resident conference days, so in that way they allow us time for education.” Forty-six percent reported that NPPs in the ED made the workload lighter or much lighter, although it should be noted that only 6% reported a decrease in documentation time.

Finally, a growing trend at academic centers is NPP “residencies” and “fellowships,” one-year post-graduate medical education program for NPs and PAs during which many are called residents or fellows, despite fewer clinical hours than a physician intern 2,3 . The presence of such a GME program for non-physicians significantly

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increased the incidence of at least one procedure forfeited and increased the number of procedures forfeited by 1400% (median 7 vs 0.5). Twice as many residents at programs with NPP GME programs reported forfeiting at least one educational ED patient than programs without such NPP programs.

This is the first empiric evidence supporting ACOEP and RSO’s prior statements warning of the repercussions of post-graduate NPP training and federal funding for NPP post-graduate education. 4,5 –•–

1. Chekijian SA, Elia TR, Monti JE, Temin ES. Integration of Advanced Practice Providers in Academic Emergency Departments: Best Practices and Considerations. Aem Educ Train. 2018;2(Suppl Suppl 1):S48–55.

2. Chekijian SA, Elia TR, Horton JL, Baccari BM, Temin ES. A Review of Interprofessional Variation in Education: Challenges and Considerations in the Growth of Advanced Practice Providers in Emergency Medicine. Aem Educ Train. 2021;5(2):e10469.

3. Tsyrulnik A, Goldflam K, Coughlin R, Wong AH, Ray JM, Bod J, et al. Implementation of a Physician Assistant Emergency Medicine Residency Within a Physician Residency. West J Emerg Medicine Integrating Emerg Care Popul Heal. 2021;22(1):45–8.

4. Moreno LA, Aintablian H, Sutter RE, Hornack CL, Jaquis B, Gallahue FE, et al. Joint Statement Regarding PostGraduate Training of Nurse Practitioners and Physician Assistants [Internet]. 2020 [cited 2021 Apr 27]. Available from: https://www.aaem.org/UserFiles/file/AllEMorgjointstatementrepostgradtrainingofNPandPAs.pdf

5. Aintablian H, Stahl G, Jasani G, Hughes HR, Beaulieu A, Naik N, et al. Joint Statement Opposing Expanding Graduate Medical Education Funding to Nurse Practitioners and Physician Assistants [Internet]. 2020. Available from: https:// acoep.org/blog/2020/03/03/joint-statement-opposing-expanding-graduate-medical-education-funding-nursepractitioners-physician-assistants/

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ANOTHER SUCCESSFUL SPRING SEMINAR

Thank you to our attendees, speakers, and presenters for making the 2023 Spring Seminar such a success! Event Chair Christopher Colbert and Vice Chair Andy Little put together an amazing lineup for the general sessions and our RSO Board gathered some top notch speakers for the Resident tract.

More than 400 attendees took part in 41 lectures, 1 keynote session, 3 EM Over Easy podcasts, 2 FOEM competitions and 8 hours of dedicated content for students and residents.

We are looking forward to seeing everyone at the 2023 Scientific Assembly, August 12-16 in Washington, DC. More details to come!

Bernard Heilicser, DO, MS, FACEP, FACOEP-D

What Would You Do? Ethics in Emergency Medicine

In this issue of The Pulse, we present the case of 72-year-old male who presented to the Emergency Department with a hip fracture.

Our patient had a fall injury in the nursing home in which he resides and sustained a left hip fracture. He has a medical history of hypercholesterolemia and schizoaffective disorder. He is a Full Code status.

The ethical dilemma relates to the fact that the patient is refusing surgery and this poses a significant mortality risk if surgery is not performed.

The patient is a Ward of the State, but does manifest intermittent decision-making capacity. Is his refusal acceptable?

WHAT WOULD YOU DO?

Please visit the ACOEP DocMatter forum and share your thoughts on this case.

If you have any cases that you would like to present or be reviewed in The Pulse, email them to us at info@acoep.org.