The Pulse Winter 2023

EDITORIAL STAFF

Victoria Selley, MS, DO, FACOEP, Editor

Wayne Jones, DO, FACOEP-D, Assistant Editor

Tanner Gronowski, DO, Associate Editor

John C. Prestosh, DO, FACOEP-D

Christine F. Giesa, DO, FACOEP-D

EDITORIAL COMMITTEE

Victoria Selley, MS, DO, FACOEP, Editor

Christine Giesa, DO, FACOEP-D

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TABLE OF CONTENTS

PRESIDENT’S REPORT

Timothy Cheslock, DO, FACOEP

THE ON-DECK CIRCLE

Brandon Lewis, DO, MBA, FACOEP, FACEP

WOMEN’S COMMITTEE UPDATE

Nicole Vigh, DO, MPH

PHYSICIAN WELLNESS COMMITTEE UPDATE

Michelle Wallen, DO, MS

WHAT WOULD YOU DO? ETHICS IN EMERGENCY MEDICINE

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

PRESIDENT’S REPORT

Timothy Cheslock, DO, FACOEP

NEW YEAR, NEW PARTNERS

It is amazing how quickly time passes us by. It seems like just yesterday that we were all together for Scientific Assembly and already we are embarking on a new year! The whirlwind of events surrounding holidays and family gatherings are now in the rearview mirror while the never-ending demands of our departments leave little time to ponder the future and where we are headed. Thankfully your ACOEP board has a plan for this new year, and I wanted to spend a few minutes sharing those plans with the membership.

One of the challenges we have faced over the last few years was how to continue to provide high quality service to our members in light of the rising cost of business. Our plan was to transition away from a physical office space and our own staff to an association management model of services. This has helped save the college financially over the last three years and placed us in a much more stable financial position looking to the future. With the transition to an association management model, there have also been challenges. Many of these are not seen by the membership and that is intentional. Our goal is to be able to conduct the business of the college, provide stellar personal service to our members and continue to produce the best CME in the Emergency Medicine domain for each of you! We continue to advocate

for our members across the spectrum of not only Emergency Medicine but the healthcare environment in its entirety, whether it be governmental, educational or in the clinical setting. Finding the right partners in helping us meet those demands can be daunting.

Over the last few years, we have partnered with the Kellen Company for our management services. They have helped us make the initial transition away from our previous management structure and helped us navigate the challenges of the pandemic. In re-evaluating our relationship with Kellen, the ACOEP board felt strongly that we needed more than what Kellen has been able to provide us on many fronts. Therefore, as of January, we have entered into a new agreement with Affinity Strategies as our management partner. I am excited to see what lies

ahead for us and this new partnership. While the daily operations of the college will remain seamless to the membership, look forward to enhancements at our future meetings and events and a general refresh of some of our branding and outreach!

I am excited to announce our new Executive Director, DeAnna McNett will be part of this team. Many of you may know DeAnna from her previous work with both ACEP and CORD. She comes to us with a wealth of knowledge and experience that is sure to help propel the college forward in the coming years. In addition to DeAnne, you will see several other new faces in the coming months. Liz Shumaker, Sarah White and Mary Kate Leon are but a few of the others from Affinity that will be partnering with the ACOEP team. You will find more information about

OUR GOAL IS TO BE ABLE TO CONDUCT THE BUSINESS OF THE COLLEGE, PROVIDE STELLAR PERSONAL SERVICE TO OUR MEMBERS AND CONTINUE TO PRODUCE THE BEST CME IN THE EMERGENCY MEDICINE DOMAIN FOR EACH OF YOU!”

them and how to reach them as you continue reading this edition of The Pulse. I also encourage you to meet them in person when we gather in Phoenix in April.

Speaking of Phoenix, be on the lookout for registration information for Spring Seminar coming your way! We are excited for a new venue this year

in the Phoenix area! It is a beautiful resort offering many amenities that will be enjoyable for the whole family! As is tradition, we look forward to this family-friendly venue where you can come and get a stellar educational experience and still have time to spend with family, friends, and colleagues in a social setting.

Thank you for your support of the college! Please reach out to me should you have questions, concerns or needs that I may be able to assist you with! I look forward to seeing you in Phoenix! – • –

THE ON-DECK CIRCLE Brandon Lewis, DO, MBA, FACOEP, FACEP

A GENERATIONAL CHANGE

THE CENTERS FOR MEDICARE AND MEDICAID SERVICES HAVE INTRODUCED MASSIVE CHANGES IN HOW WE WILL GET PAID FOR THE WORK THAT WE DO.”

As we approach the new year, emergency physicians across the country can look forward to huge changes in how we work on a daily basis. The centers for Medicare and Medicaid services have introduced massive changes in how we will get paid for the work that we do. This has huge potential impacts on our practices and the healthcare system across the board.

All emergency physicians know that when billing a patient for your care, the level of services is determined by how you have documented the encounter. For example, the number of history elements that are included in your history of present illness (HPI) can determine whether you get paid for a low-level visit or high-level visit. Similarly, for a higher level visit a comprehensive review of systems and a detailed physical exam is required. Unless you meet a set number of systems reviewed and physical exam body parts described, you cannot recognize the true level of service that you have provided, regardless of how sick the patient is.

The results of this is that we as physicians end up having to spend extra time documenting a chart that may include things that are not relevant to the patient’s current medical condition. If not done properly it often results in under coding for the true level of service that you have provided. As a patch many practicing emergency physicians develop macros or templates that they used to document, or have hired a scribe to add most of this documentation for them.

The end result is that many charts often times are full of “click box “entries that do little to tell the story of the patient’s true condition or what transpired during the visit. Medical decision-making entries in the chart are usually fairly brief and also not as descriptive or useful as they should be.

Starting January 1, this all changes. While there is certainly the potential for some negative effects associated with this change, the new CMS documentation changes will focus more on the medical decision making that actually occurs during the visit and less on data entry.

Level of service will now depend on three factors: 1. the number and complexity of problems addressed, 2. the amount or complexity of data to be reviewed and analyzed, and 3. the risks of complications and/or morbidity and mortality to the patient you are seeing. Most of these things are all captured in your medical decision-making portion of the chart. The amount of history, review of systems and examination documented will play no role in how the level of service is determined. As usual, there are some specific terms and items that coders will be looking for to determine how complex the case was and how much risk is involved. I highly recommend that you talk to

your coding team about what they are looking for in these areas.

In theory, a history and physical exam are not even required for coding purposes. Of course, we all know that a chart is more than just a coding document. More importantly the chart functions as a peer-topeer communication of the patient’s condition and treatments that were offered. Also the chart serves as a record of the patient’s condition and your thought process to defend you in the event of medical malpractice assertions. These things of course do necessitate a reasonable history and physical exam, so we cannot throw the entire baby out with the bath water so to speak.

While one may call me a “glass is half-full” kind of guy, I think there are some positives that come from these changes. Going forward the time that I spent documenting a patient encounter will focus much more on truly “telling the story” of the encounter and far less time will be spent and checking boxes to meet arbitrary coding requirements for history and physical exam elements. The only person that may suffer from this is my scribe as the utility of scribes may be a far less value going forward! Good luck with these changes and let us know if there is anything ACOEP can do to help you adapt to the new world of documentation! – • –

WOMEN’S COMMITTEE UPDATE

By Nicole Vigh, DO, MPH

Thank you to everyone who joined us for the ACOEP Fall Scientific Assembly in the vivacious Las Vegas, Nevada! As always, the Women’s Committee was thrilled to have such a great turnout for all of our events! Our Women’s Luncheon was very well attended including by a special guest, ACOEP President Dr. Timothy Cheslock. At our luncheon we honored our 2022 Willoughby Award winner, Dr. Alexis LaPietra. The Willoughby Award is presented to women physicians by the ACOEP Women’s Committee to recognize the role they play in the profession. After completing her emergency medicine residency at St. Joseph’s Regional Medical Center in Patterson, New Jersey, Dr. LaPietra completed an EM Acute Pain Management Fellowship at St. Joseph’s. After her fellowship she has held increasingly important roles that have distinguished her as one of the leading acute pain management experts in the nation! As an attending physician at St. Joseph’s Dr. LaPietra has served as Director of the Pain Management fellowship, Director of the Addiction and Mental Health Fellowship, and is currently System Chief of Pain Management and Addiction Medicine.

Dr. LaPietra has used her expertise and passion in pain management and addiction as a platform to train other physicians and the general public on proper pain management practices. She founded and chaired the ACEP Pain Management and Addiction Medicine Section and is an executive board member for the Department of Justice’s Coalition for Opioid Assessment and Response. ACOEP and the Women’s Committee is proud to have Dr. LaPietra as part of our organization; congratulations Dr. Alexis LaPietra!

We had an excellent panel discussion entitled Creating a Climate of Inclusiveness. This panel discussion was inspired by The AllEM DEI Initiative Task Force, which Dr. Carrick and a few other members of our committee are participating in. All the national EM organizations are collaborating with an overarching purpose of creating an EM Best Practice related to DEI. Our panel consisted of many prestigious individuals from around the country at various stages in their careers.

Dr. Kristina Domanski, MD, serves as Core Faculty and Assistant Research Director for the EM Residency at Kirk Kerkorian School of Medicine at

University of Nevada, Las Vegas. Dr. Tracy Sanson, MD, has been a director in the US Air Force and the University of South Florida, currently practices as an independent contractor and is a consultant and educator on leadership development and medical education. She was recently awarded the American College of Emergency Physicians Judith Tintinalli Award for Outstanding Contribution in Education. Dr. Jacob Altholz is a second year resident at the University of Nevada, Las Vegas. He chairs the residency program’s Diversity and Inclusion Committee and coordinates hospitalwide efforts of social justice, inclusion and compassionate care. Dr. Nathalie Hibbs is a third year chief resident in Las Vegas. She came to the United States from Columbia as a child and attended medical school at Touro

University in South Nevada. She has a passion for diversifying the field of EM. Dr. Lisa Mannina, MD, served in the Air Force as a member of the tactical critical care air transport team for seven years and now works with the Mountain View EM Residency program as Simulation Director, DEI Committee Director and Assistant Research Director.

Our panelists discussed a lot of interesting points and brought up some eye-opening and thoughtprovoking information. During our panel discussion we explained the principles and importance of diversity, equity and inclusion (DEI). We recognized some barriers to DEI initiatives that can be experienced individually or within the ED. We came up with strategies to create a culture of inclusiveness and break

through these barriers. We discussed how we can open dialogue and shift perspectives on DEI. We pointed out the types of bias that may result in microaggressions, as well as resources to learn more about your personal biases and what we can each do to advocate for DEI. It was a great discussion, and our committee members are excited to bring this information to the All-EM DEI Initiative Task Force!

We thank all those who participated in the ACOEP Fall Scientific Assembly; we are so excited to have had such a great turnout! Please remember to check out our Facebook page to stay informed regarding future events. We look forward to seeing you all at the ACOEP Spring Seminar in Phoenix, Arizona, April 1-5, 2023! – • –

Michelle Wallen, DO, MS

HELP STOP THE STIGMA, BECAUSE IT COULD SAVE A LIFE

What is stigma? It is when someone views you in a negative way because you have a trait or characteristic that is thought to be a disadvantage. This stigma toward persons with mental illness in the medical profession can and has led to discrimination. It is a very large concern for healthcare practitioners as a barrier for reaching out for help. From work applications asking disclosure to mental illness questions, required disclosure for obtaining or renewing medical license, staff being discouraged not to talk openly about psychological problems, and simply dismissing talking about difficult and emotional issues in the workplace, the stigma over the years has forced many physicians to avoid seeking mental health treatment. This causes several concerns, which include delay in seeking care, poor quality of mental and physical care, and overall, a general feeling of emptiness, sadness, no purpose and increased risk of suicide.

We need to take a stance to change the culture and focus on the importance of stigma reduction and breaking the silence. This past October, Society for Academic Emergency Medicine ran a campaign

“StopTheStigmaEM.” This was created to bring awareness, advocacy and actions for breaking down the barriers to mental healthcare in Emergency Medicine. As Emergency Medicine Physicians, we pay attention to our patients and their needs. We need to use this empathy and compassion to focus on our colleagues, residents, students, and most importantly, ourselves. We cannot help others become well if we are not well ourselves.

So how do we deal with stigma? First and foremost, do not be afraid to get treatment. Acknowledge the fact that it is “Ok not to be Ok.” Seeking counseling, connecting with others who have mental illness and getting support can help you gain self-esteem. Make sure you do not isolate yourself. You may be initially reluctant to tell anyone about your mental illness, but family, friends and members of your community can offer support if they are aware. Join a support group, such as the National Alliance on Mental Illness (NAMI), which offer programs to help reduce stigma.

To help in this pursuit, we need to normalize the seeking of mental health care. Approximately one in five adults will experience a diagnosable

… IT IS ‘OK NOT TO BE OK’”

mental health condition during their life. Because of this, it is imperative to support and monitor the well-being of our colleagues. Emergency Medicine is a demanding profession, and it is

normal to feel the need for help at times. Do not ever feel ashamed, and do not feel alone. Help stop the stigma, because it could save a life. – • –

RESOURCES

Mayo Clinic

Mental health: Overcoming the stigma of mental Illness StigmaFree me. National Alliance on Mental Illness. https://www.nami.org/Get-Involved/Take-the-stigmafree-pledge/ stigmafree-me

What is stigma? Why is it a problem? National Alliance on Mental Illness. https://www.nami.org/stigmafree

Stigma and mental illness. Centers for Disease Control and Prevention https://www.cdc.gov/workplacehealthpromotion/tools-resources/ workplace-health/mental-health/index.html

Help Stop the Stigma University of Utah Health https://healthcare.utah.edu/hmhi/news/2021/stop-stigma.php

Stop Stigma Sacramento https://www.stopstigmasacramento.org/ SAEM

Hotlines and Call Centers: Crisis Text Line: Text HELP to 741741 National Suicide Prevention Lifeline: 1-800-273-TALK (8255) NAMI HelpLine M-F from 10am-10pm ET: 1-800-950-NAMI(6264) or info@nami.org or text NAMI to 741-741 Physician Support Line 1-888-409-0141 Call or Text 988 Suicide and Crisis Lifeline

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

What Would You Do? Ethics in Emergency Medicine

In this issue of The Pulse, we will review the dilemma presented in the Fall 2022 issue.

Our patient is a 69-year-old female being admitted for septic shock. She has a history of osteomyelitis, hypertension and dementia. Her hemoglobin had fallen from 7.0 to 6.3. She has two daughters, one being a Jehovah’s Witness, while the other is not. The patient lacks decision-making capacity.

Daughter A was a Jehovah’s Witness and would not consent for a transfusion. Daughter B, not being a Jehovah’s Witness, wanted everything done to keep her mother alive. There is no documentation indicating the patient is a Jehovah’s Witness. Additionally, daughter A claims to be a Durable Power of Attorney for Health Care but lacks documentation to that effect.

WHO HAS STANDING IN MEDICAL DECISION-MAKING FOR THE PATIENT?

We received the following two responses:

Here is a response from Stephen J. Vetrano DO, FACOEP, FACEP, EMT

Remember that the health care proxy/decision maker is supposed to make decision on behalf of the patient, not themselves. Part of the discussion should include what does the mother want, not what the daughters want. If the mother is not a Jehovah’s witness, the daughter has no right to infer her religious beliefs on the mother.

Here is a response from Rudolph

Bescherer DO, FACOEP

1. Do either persons have documentation to substantiate that they are actually related to the patient? In some cases, the physician knows the patient and family already, but often we are not afforded this luxury. If we cannot reasonably ensure that they are in fact the patient’s daughters, then the patient should be treated under implied consent with whatever is appropriate for the condition.

2. I have treated a lot of patients who practice as Witnesses and all of them, upon request, have produced their own card refusing blood transfusion. If the patient did not arrive with hers then there is reasonable doubt that the patient subscribes to these particular beliefs.

3. Presuming that both provide identification to substantiate their relationship to the patient, typically the eldest child takes precedence in the absence of an available durable POA for healthcare. However, here we are told that a durable POA exists but we do not have it and therefore we cannot prove which person is authorized to speak for the patient. In the event of uncertainty with regards to who is able to speak for the patient, and particularly when there is a disagreement with this uncertainty, then typically the best path forward would be to treat within the least restrictive bounds

without irreversibly withholding a medically indicated treatment while consulting the institutional ethics board. If the debate were full code status versus comfort measures only then I would make the patient full code until further clarification.

In this case I would articulate within the chart that there is reasonable doubt as far as whom is able to speak for the patient and that a disagreement exists specifically with regards to the transfusion, but otherwise there is presumably agreement with regards to other aggressive care for the septic shock. I would consult the hospitalist/intensivist as the patient is most certainly going to be admitted, and if they concur we could order the transfusion with both physicians signing a consent form. If

daughter A produces the durable POA and daughter B cannot produce a more recent document showing that she is the durable POA then the transfusion can be stopped. Otherwise, the ethics committee can render an opinion as soon as practicable.

We very much appreciate and thank Dr. Vetrano and Dr. Bescherer for their insightful and thoughtful responses.

As the Director of the Hospital Ethics Program, I had opportunity to further consult on this situation.

If durable power of attorney for healthcare form was provided, that individual would be the appropriate medical decision maker for the patient. In the absence of that documentation, under the Illinois Healthcare Surrogate Act, both daughters have equal standing. If definitive proof was to be presented that the patient is,

indeed, a Jehovah’s Witness, from an ethical perspective it would be most appropriate to honor that wish. In the absence of such documentation, if blood is necessary, both daughters have equal standing and they would need to come to some type of understanding between the two of them regarding blood transfusion.

A durable power of attorney was not documented, nor was proof of the patient being a Jehovah’s Witness.

WHAT HAPPENED?

Fortunately, daughter A acquiesced to daughter B, and the patient did receive a blood transfusion and was subsequently discharged to a nursing home. Had this not occurred, there would have been a need for legal guardianship appointed. We got lucky.

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

CME Your Way

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CME via In-Person Events

The ACOEP Spring Seminar and Scientific Assembly are your choices to reconnect, network and earn CME live and in person. Save the date for the 2023 Spring Seminar, April 1-5, at the Hilton Phoenix Tapatio Cliffs Resort, Phoenix, Arizona.

CME via Webinars

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