March-April 2004

S A E M

NEWSLETTER

Newsletter of the Society for Academic Emergency Medicine

901 North Washington Ave. Lansing, MI 48906-5137 (517) 485-5484 saem@saem.org www.saem.org

March/April 2004 Volume XVI, Number 2

Research Fund Continues to Grow

PRESIDENT’S MESSAGE

Critical Care Certification: One (Giant) Step Back…

On December 23, 2003, SAEM was notified by the American Board of Emergency Medicine (ABEM) of two important decisions regarding critical Donald M. Yealy, MD care medicine (CCM) training and certification of emergency medicine (EM) trained physicians. First, the American Board of Internal Medicine and the American Board of Pediatrics decided to continue to oppose any change allowing EM trained physicians access to the U.S. (ACGME) certification process. Secondly, the Internal Medicine based programs – traditionally the site where EM graduates were accepted and trained – will now shift from requiring 75% to 100% of fellows be internal medicine trained before entry. These two decisions have created a professional exorcism for EM physicians already trained in CCM and those seeking this training. ABEM has invested great effort and resources on this issue for over a decade – their work, while not producing the desired result, has been outstanding. Right now, ABEM has no viable options to reverse these decisions.

SAEM has long supported access of EM trained physicians into these programs and certification process. Our Society, our Annual Meeting, and our journal have been havens for those EM CCM experts to share their views – beginning with the late Peter Safar, MD, and his many trainees through the current pool of outstanding academic EM intensivists. Much of our early and current recognition comes from this support and the clear recognition that EM and CCM are inseparable – together, we care for the sickest when needed and unplanned, and we create the knowledge to improve the care of those patients.

Optimal approaches to injured patients, patients with outof-hospital cardiopulmonary arrest or sepsis – three of the largest ‘CCM care categories’ – are central to the scientific base of both EM and CCM (as well as other disciplines).

The most important advances in each have been accomplished with EM and CCM MD efforts – fluid resuscitation, neural protection (including cooling), drug therapy, early external cardiopulmonary support, and early goal directed sepsis therapy. (continued on next page)

Frank Counselman, MD Eastern Virginia Medical School SAEM Financial Development Committee Recently all SAEM members received the SAEM Research Fund brochure. As outlined in the brochure, the goal of the Research Fund is to raise sufficient monies to establish a research endowment. The accrued interest from the endowment will fund current and future research activities. These activities include the current Research Grants, Institutional Research Training Grants, Scholarly Sabbatical Grants, the Medical Student Interest Group Grants, and the Medical Student Research Grants, as well as supporting new research initiatives for the benefit of the membership.

The May/June issue of the Newsletter will include the announcements of the 2004-2005 grant recipients. It will make you proud to read about the grant recipients that your Research Fund is helping to support. Unlike other Emergency Medicine funding sources, our funds support research training grants. These grants are not directed to a specific area of research and are open to all members.

Last year, 151 members and friends contributed over $42,000 to the Fund. In addition, SAEM contributed $250,000. If you made a contribution last year, we thank you, and ask that you consider making a similar or greater contribution this year. If you did not have the opportunity to contribute last year, we encourage you to join your colleagues this year and make a generous donation.

Challenge yourself, your colleagues and your alumni to meet or exceed the contributions made last year. One-hundred percent of your contributions go directly to the Fund; SAEM assumes all of the administrative costs.Your donation is 100% tax deductible.You may pay by check (payable to “SAEM Research Fund”) and mail to the SAEM office or you can make a donation on-line through the SAEM website.

Call for Medical Student Volunteers The Program Committee for SAEM is soliciting a request for medical students who are interested in working at the 2004 Annual Meeting in Orlando, Florida on May 16-19. The Program Committee will waive the registration fee for a limited number of medical students willing to assist with some administrative duties. Each medical student will be responsible for coordinating evaluations at assigned didactic sessions during two half days and one luncheon session. The Annual Meeting provides a unique opportunity for medical students to familiarize themselves with the research and educational interests of emergency medicine. In return the students will receive a complimentary registration fee. Interested medical students should contact Deborah Diercks, MD by e-mail dbdiercks@ucdavis.edu with the a subject line labeled, “Medical Student Volunteer for Annual Meeting.”

President’s Message

(Continued)

Dr. Safar had a vision of a continuum of care – from the first recognition of illness and injury (often the field), through the ED, ICU, hospital and return to home. Combined training and collaboration were the keys to this chain of care.

Now, decisions based on other needs or perceptions – seemingly ‘political’ rather than care or vision based – have threatened this evolution of EM CCM training and certification. Our challenge is not to let the other part – the collaboration to create and disseminate the knowledge of how to improve care – wither while regrouping on the former.

Recognizing this, what should we do? SAEM will continue to support those doing CCM work – trained EM/CCM physicians and all others. Our Society welcomes the knowledge, skills and efforts, and will continue to be a place to share, learn and grow. SAEM will also continue dialogue with those who can help change the future – other organized medical groups and ABEM – recognizing that in the near future, progress will likely be small, if present.

Our EM CCM physicians should continue their excellence, and use this as a ‘grass roots’ mechanism to reapproach

the issue, focusing on the accomplishments and the future rather than previous decisions. Finally, all of us should constructively share our thoughts with our colleagues locally who may be involved or could be involved - other non-EM physicians and influentials – to educate and enlist support. In many ways, this path – while involving far fewer people – parallels that of the struggle EM faced and overcame 30+ years ago. This is a big setback – but it does not change the reality of EM and CCM being ‘joined forever’.

Who are the Principal Investigators in Emergency Medicine?

Amy Kaji, MD Harbor - UCLA SAEM Research Committee from word-of-mouth and self-report. As a result of an e-mail sent by Dr. Clifton Callaway last year to the members of SAEM which asked what sources of funding they were using at the time, we were able to identify various non-NIH grant recipients.

The Centers for Disease Control (CDC), Department of Defense (DOD), Robert Wood Johnson Foundation (RWJF), and the Emergency Medical Services for Children program (EMSC) are all important, prestigious sources of large research funding. Information regarding CDC-funded projects is listed at www.cdc.gov/ncipc/res-opps/extra.htm, and details regarding RWJF projects are available at www.rwjf.org/programs/grant.Detail. Created in October 2001, PECARN is the first federally funded national network for research in Emergency Medical Services for Children (EMSC). In June 2001, the Health Resources and Services Administration (HRSA) and the Maternal and Child Health Bureau (MCHB) began to invite proposals from established clinical investigators to participate in forming collaborative research partnerships among various academic and community-based hospitals. For further details, please see the June 2003 issue of Academic Emergency Medicine (vol.10, no.6, pp. 661-668).

Other foundations that are currently funding researchers in emergency medicine include the American Heart Association (AHA), the American Geriatric Association (AGA), the American Legacy Foundation, the William Penn Foundation, the Firearm Injury Center (FICAP), the Children’s Health Insurance Project (CHIP), The Mayday Fund, Hartford Foundation/American Geriatric Society, the National Center for Medical Rehabilitation Research, and the Wallace Coulter Foundation. As there are numerous foundations that are interested in providing financial support to researchers, it is incumbent upon us to utilize these resources and further our specialty’s research endeavors.

We hope to provide a more comprehensive list of where researchers in emergency medicine derive their funding and to ultimately guide novice investigators towards successful grantsmanship. If you wish to provide information regarding your own personal experience with grant writing or reviewing, please email your contact information to the Research Committee at saem@saem.org. (continued on page 16)

Competition for research funds is extremely stiff, and many sound proposals are not funded. Although the federal government is the largest single source of research funding, financial support is also offered by many agencies, foundations, and corporations. The preparation of a well-written proposal and meticulous planning are critical to successful grantsmanship. It is also important to select an appropriate funding agency, since the investigator’s objectives must be consistent with those of the funding organization. While most grant applications have a number of similarities, each funding agency may also have unique requirements. Thus, applicants should scrupulously follow the application criteria of the agency or institution from which they are seeking support.

Many consider successful grantsmanship to be a reliable marker of successful research development, and novice researchers look to more experienced researchers for guidance and advice regarding grant writing strategies. How well an institution is funded is often correlated with the level of expertise in a given area of study. Thus, identifying projects and investigators who are funded help familiarize us with the types of grants offered, respective areas of interest, and centers of academic excellence.

Over the last three years, the SAEM Research Committee has compiled a list of funded emergency medicine investigators, which was first published in the SAEM January/February 2002 Newsletter. Whereas many researchers in emergency medicine serve as co-investigators or site investigators for research, we have chosen to list only principal investigators.

Last year, the list included 48 NIH-funded projects (14 career development awards and 34 project grants) and 10 non-NIH grants. The current list includes 88 NIH-funded grants (19 career development awards and 61 project grants) and 45 nonNIH grants. In addition to some projects that we overlooked last year, the updated list includes the newly funded projects beginning in 2003, as well as 10 project grants that are terminating this year. Information regarding the NIH-funded projects may be obtained from the CRISP database available at www.nih.gov.

Without a central database, non-NIH grants are significantly more difficult to identify. We compiled this list from an internet search of http://fdncenter.org, www.naicrc.org as well as 2

Program Committee Update: 2004 Annual Meeting Judd Hollander, MD University of Pennsylvania Chair, SAEM Program Committee This year, we had a record number of abstract submissions for the Program Committee to evaluate. We also accepted more abstracts for presentation than ever before. Overall, 502 of 997 abstracts were accepted for presentation.

Each submitted abstract is subject to peer review by approximately 6 abstract reviewers. Each expert grades each abstract on 9 individual components that are totaled to give a final abstract score that ranges from 0 to 20. An average abstract score is calculated for each abstract.

Because no scoring system is perfect we have several quality checks within the system. Within each category, we review the mean scores for each reviewer to make sure that one category does not contain exceptionally hard or easy reviewers. We review the range of scores within each category and compare that to the study designs submitted within each category to reduce biases for or against a particular type of research. We review a report of all the scores for each individual abstract to try to make certain that an abstract with a single low score did not end up with an average below the cutpoint. We review a report of all comments sent in by abstract reviewers to look for data splitting or duplicate submissions.

These are just a sample of the reports that we review to make the abstract submission process as valid as possible.

There were a large number of abstracts submitted in each abstract submission category reflecting the breadth of our specialty.

Category Abdominal/GI/GU Administrative Airway Cardiovascular (non-CPR) Clinical Decision Guidelines Computer Technologies CPR Diagnostic Tech/Radiology Disease/Injury Prevention Education/Prof Development EMS/Out-of-Hospital Ethics Geriatrics Infectious Disease Ischemia/Reperfusion Neurology Obstetrics/Gynecology Pediatrics Psychiatry/Social Issues Research Design/Meth/Stats Respiratory/ENT Disorders Shock/Critical Care Toxicology Trauma

Over the years, the quality of our science has also improved. The abstract submission process requires each submitter to self report a study design category for their work. This year, abstracts were submitted with the following distribution of study design.

Randomized controlled trial Nonrandomized comparison Prospective cohort study Cross sectional study Prospective observational study Before and after trial Retrospective case control Retrospective case series/cohort Survey Other Basic Science

57 36 115 47 168 38 45 193 140 95 63

Thus more than 40% of the submitted science included prospective clinical studies.

The meeting will include a litany of great research that spans the full spectrum of academic emergency medicine, including clinical disease, laboratory investigation and educational initiatives. The outstanding didactic sessions, photography exhibits, and innovations in medical education exhibits should make this meeting another great one.

HIPAA Session at the Annual Meeting

# abstracts submitted 19 110 45 71 40 15 29 61 74 90 64 7 26 46 16 31 12 73 31 14 26 12 36 40

Alan E. Jones, MD Carolinas Medical Center SAEM Research Committee On April 14, 2003 all parties subject to the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and its Privacy Rule were required by the federal government to be in compliance with its standards. The Privacy Rule was issued to protect the privacy of health information that identifies individuals and it affects researchers who require access to or use of individual identifiable health related information. This rule changed the face of clinical research forever. In response to a request from the SAEM Board of Directors, the SAEM Research Committee has developed a didactic proposal that will be featured at the 2004 Annual Meeting and will focus on both HIPAA’s effect on clinical research and methods researchers can use to cope with the new restrictions and requirements. This didactic session will be based on the Department of Health and Human Services publication “Protecting Personal Health Information in Research: Understanding the HIPAA Privacy Rule.” The session will feature three outstanding and highly qualified speakers, Dr. Sue Fish, Dr. Carlos Camargo and Dr. Gabor Kelen. The session promises to be informative and give researchers a thorough understanding of the privacy rule and its impact on clinical research. The session will be held on May 18 at 1:30 pm. We hope to see everyone in Orlando.

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AEM Consensus Conference

Call for Papers

Informatics and Technology in Emergency Department Health Care 8:00 am

Introduction: Goals and Objectives

8:30 am

Keynote Address - "The problem and the promise of informatics and technology in Emergency Medicine"

9:30-11:30 am

Morning Consensus groups

“Using Information Technology to Improve ED Patient Care” The use of information technology (IT) in the ED is bound to increase. Information technology has the potential to quickly provide data that can be used to study essential topics related to the practice of emergency medicine. The questions that could be answered with good ED IT are nearly endless, and include how to reduce medical errors, assure quality and equal ED care, document and monitor ED overcrowding, identify emerging infectious diseases or bioterrorism, and mend the unraveling safety net. However, there are currently no standards for ED IT. There is no definition of essential components of an adequate information system, of universal minimum requirements for data collection, of common language to allow information exchange. Unless the emergency medicine academic community has input into these issues, we will lose the chance to design and implement this powerful clinical tool in the way best suited to our needs.

The 2004 AEM Consensus Conference will be held May 15, 2004 as a pre-day session before the SAEM Annual Meeting in Orlando. The conference will address the issues of developing ED IT standards for design, implementation, data recording, information exchange and IT research; developing an ED IT research agenda; determining how systems issues and clinical practice patterns need to be considered in developing good ED IT; and determining how ED clinical IT can impact ED residency training.

AEM has issued a Call for Papers on “Using IT to Improve ED Patient Care.” Original contributions describing relevant research or concepts in this topic area will be considered for publication in the Special Topics issue of AEM, November 2004, if received by April 1, 2004. All submissions will be peer reviewed by guest editors with expertise in this area. If you have questions, contact Michelle Biros at biros001@umn.edu.

Watch the SAEM Newsletter and the AEM and SAEM websites for more information about the Consensus Conference.

Each consensus group will attempt to address the same basic questions with respect to their content domain: ●

●

●

●

What literature exists regarding this topic and the effect on patient care, financial outcomes, efficiency, scalability, staff development, and clinician satisfaction?

What studies need to be done to fill knowledge gaps and reach consensus?

What are our best identifiable measures and outcome parameters for tracking progress?

Based on existing data, do we have a preliminary consensus recommendation while awaiting more studies?

1) Where's the beef?

The Promise and the Reality of Clinical Documentation 2) Data + Algorithms = Action The Decision Support and Computerized Physician Order Entry Landscape 3) Disparate Systems, Disparate Data Integration, Interfaces, and Standards 11:30 am

Lunchtime Keynote Address

1:00-3:00 pm

Afternoon Consensus groups

Medical Student Excellence Award Established in 1990, the SAEM Medical Student Excellence in Emergency Medicine Award is offered annually to each medical school in the United States and Canada. It is awarded to the senior medical student at each school (one recipient per medical school) who best exemplifies the qualities of an excellent emergency physician, as manifested by excellent clinical, interpersonal, and manual skills, and a dedication to continued professional development leading to outstanding performance on emergency rotations. The award, presented at graduation, conveys a one-year membership in SAEM, which includes subscriptions to the SAEM monthly Journal, Academic Emergency Medicine, the SAEM Newsletter and an award certificate.

Announcements describing the program and applications have been sent to the Dean's Office at each medical school.

Coordinators of emergency medicine student rotations then select an appropriate student based on the student's intramural and extramural performance in emergency medicine. The list of recipients will be published in the SAEM Newsletter.

Over 100 medical schools currently participate. Please contact the SAEM office if your school is not presently participating.

1) See One, Do One, Teach One The Future of Education and Informatics 2) The Rubber Meets the Road Real Data, Real Patients, Real Time Tracking and Clinical Results Systems 3) The Computer Is My Copilot Reporting, Data Mining, Operations Management 3:00-4:00 pm

and

Summary Presentation; Consensus Groups Findings

All SAEM members and others are invited to attend the AEM Consensus Conference. The registration fee is $50 and includes lunch. To register, complete the online SAEM Annual Meeting registration form, which is posted on the SAEM website at www.saem.org.

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Academic Announcements SAEM members are encouraged to submit Academic Announcements on promotions, research funding, and other items of interest to the SAEM membership. Submissions must be sent to saem@saem.org by April 1, 2004 to be included in the May/June issue.

Recently the SAEM Board of Directors conferred emeritus membership on Gail Anderson, MD, Richard F. Edlich, MD, PhD and George Podgorny, MD. Each of these individuals have made outstanding contributions to academic emergency medicine.

Michael Callaham, MD, has been named to a two-year term as Vice President of the World Association of Medical Editors (WAME). Dr. Callaham is currently the chair of the WAME Ethics Committee. WAME is the largest organization of medical science editors, with representation from 620 journals in 75 countries.

Donna Carden, MD, has been named Vice Chairman for Faculty Development and Research in the Department of Emergency Medicine at Louisiana State University Health Sciences Center in Shreveport. Dr. Carden is Professor of Emergency Medicine and Physiology at Louisiana State University.

Glenn C. Hamilton, MD, is a recipient of the Foundation Twenty Medal from the Australasian College of Emergency Medicine. The medal was awarded to

individuals who had significantly contributed to the development of the College during its formative years 19832003. Dr. Hamilton was the inaugural speaker at the formation of the College in 1983, became the first international fellow, and has served on the Editorial Board of Emergency Medicine, the College journal.

Edward J. Newton, MD, has been promoted to Professor of Clinical Emergency Medicine at the Keck School of Medicine at the University of Southern California. Dr. Newton also serves as the Interim Chair of the Department of Emergency Medicine at Los Angeles County/University of Southern California Medical Center.

Debra Houry, MD, MPH, has been awarded a five-year K23 grant in the amount of $699,900 from the National Institute of Mental Health to study intimate partner violence and mental health symptoms. In addition, the NIH has given Dr. Houry the NIH Loan Repayment award for two years. Dr. Houry is an Assistant Professor in the Department of Emergency Medicine and Associate Director of the Center for Injury Control at Emory University.

Jedd Roe, MD, has been named the Program Director of the Emergency Medicine Residency Program at the University of Alabama at Birmingham.

Dr. Roe is an Associate Professor in the Department of Emergency Medicine.

John B. McCabe, MD, has been named Chair of the Department of Emergency Medicine at the State University of New York Upstate Medical University in Syracuse, NY. Dr. McCabe is Professor of Emergency Medicine.

J. Stephan Stapczynski, MD, has been named Chair of the Department of Emergency Medicine at Maricopa Medical Center.

Thomas K. Swoboda, MD, MS, has been appointed Associate Director of the newly established Emergency Medicine Residency Program at Louisiana State University Health Sciences Center in Shreveport. Dr. Swoboda serves as an Assistant Professor in the Department.

Board of Directors Update The SAEM Board of Directors meets via conference call every month, as well as face-to-face meetings during the SAEM Annual meeting, the ACEP Scientific Assembly, and the CORD Navigating the Academic Waters and Best Practices conferences. This article includes the highlights from the December 9 and January 13 conference call meetings of the Board.

The Board reviewed and approved a number of budget issues including: the budget for the 2004 Annual Meeting; the annual stipend for Dr. Michelle Biros, who begins her second five-year term as Editor-in-Chief of Academic Emergency Medicine; a $20,000 contribution for the dissemination of the final report of the Institute of Medicine conference on The Future of Emergency Care in the U.S. Health System; a pilot online Evidence Based Medicine course; the budget and content of the pre-day session at the Annual Meeting on the Business Aspects of Health System Management; and the 2003 contribution to the employees' pensions.

The Board also approved the year-end Research Fund investment report submitted by Steve Dronen, MD. The yearend value of the Research Fund is $2,999,975.

The Board approved a manuscript developed by the Ethics Committee entitled, “The Ethical Debate on Practicing Procedures on the Newly Dead.� In addition, the Board devel-

oped a position statement on performing invasive procedures for teaching purposes on recently deceased patients, which is published in this issue of the Newsletter. The manuscript and position statement will be submitted to Academic Emergency Medicine for consideration of publication.

The Board reviewed the first draft of a manuscript developed by the National Affairs Committee entitled, "Financing of Emergency Medicine Graduate Medical Educational Programs in the Era of Declining Medicare Reimbursement/Support."

The Board approved the Grants Committee recommendations regarding the 2004-05 grant recipients. Information on the grant recipients will be published in the May/June issue of the Newsletter.

The Board approved a slate of nominees for the open positions on the American Board of Emergency Medicine. In addition, the Board submitted a list of academic emergency to the National Center for Injury Prevention and Control (NCIPC) at the Centers for Disease Control and Prevention (CDC).

The Board named Dr. Judd Hollander to serve as the representative to the Biochemical Markers in Patients with Acute Coronary Syndromes and Heart Failure project. The Board unanimously approved emeritus membership status for Gail Anderson, MD, Richard Edlich, MD, and George Podgorny, MD. 5

Position Statement: Performing Invasive Procedures for Teaching Purposes on Newly Deceased Patients The following position statement was approved by the Board of Directors in January 2004.

Position: SAEM believes that permission should be obtained from the family or next of kin prior to performing invasive procedures for teaching purposes on newly deceased patients in the emergency department.

Background: Emergency medicine training programs have an obligation to ensure trainees' procedural and technical skills, including abilities to perform invasive procedures. Historically, many training programs have taught invasive procedures on recently deceased patients because of the realism, high

quality, and accessibility.

A fundamental requirement of the profession of emergency medicine is to maintain public and individual trust.

Therefore SAEM believes that permission should be obtained from the family or next of kin prior to teaching invasive procedures on newly deceased patients in the emergency department.

It is recognized that the recommendation to obtain permission may limit teaching opportunities on the recently deceased due to physician discomfort asking for permission, family unwilling-

ness to grant permission, family inaccessibility, and acute grief that impairs the discussion. It is acknowledged that other teaching sources such as cadavers, simulators, and animal laboratories are frequently employed for teaching invasive procedures but are less accessible, less realistic, and very costly.

Despite these acknowledged challenges, it is believed that competent emergency physicians can be trained within the constraints of the SAEM position to obtain permission.

Ethics Corner: Are We Teaching Our Residents the Ethics of Private Practice?

Jason A. Hughes, MD Texas Tech University SAEM Ethics Committee In a recent on-line article in the American Medical Association newspaper, it was noted that people who are “squeaky wheels” need some extra care and attention. In the same article, it was also noted that we should cater to them because they are usually paying patients and thus they pay the bills, so to speak.

This issue is an important one, as many residency programs are situated in areas where patients are either poverty stricken, or having difficulty making ends meet. Institutions such as these are excellent training grounds as they give us the ability to care for people who are usually in desperate need, and we are rarely put in a situation where “squeaky wheels” try to make their presence known.

We have seen some patients in our own hospital feign chest pain in order to obtain prescription refills that are “free”.

Others have been brought in screaming at the top of their lungs due to abdominal pain. We, as teachers and role models, hopefully show the residents that after a careful examination and treatment plan, there should be an inventory of the quiet patients in the emergency department who could easily have life threatening conditions.

However, it seems rare that people who are fairly well to do present to our county hospital, which is located five minutes from the US-Mexican border. In the private institutions across our country, it is suspected that we have a different problem.

The question is how to resolve this in a quiet, ethical manner.

In many private institutions we have seen patient families insist on “the best care” for their relatives; they will sometimes go through a checklist and let the emergency physician know what plan of action needs to be taken. At times, families seem to be more aggressive concerning their care, and they seem to be lacking in the understanding of triage in spite of careful explanations.

For an emergency department with single physician coverage, catering to the whims of the family can eat away precious time. Others in the ED could have conditions requiring your

immediate attention. However, not catering to certain whims might lead to concern over reprimands from administration as well as letters of complaint.

The overall question could easily be summarized as follows: “If the CEO of your particular hospital limps into your ED with an ingrown toenail, should this take precedence over other patients?”

As a teacher of medicine, it would seem that this is a clearcut answer…until we are placed in that very situation.

In our teaching, it would seem appropriate to discuss the private practice world didactically and practically. Although most programs do not condone a large amount of moonlighting, a degree of moonlighting may be appropriate if carefully monitored. There should be a free discussion about such issues as this that seem more likely to occur in a private setting.

What is the answer to the “squeaky wheel” problem? It seems to be institution dependent, but it is important to have the backing of the ED director. Waxing philosophical to a patient and family about their inappropriate “squeakiness” is yet another waste of time and could lead to an argument.

Calling their physician at home may assist you tremendously as these patients are often well known. These are only a few suggestions. The main one is to help our residents understand these types of dilemmas so they may develop their own plan of attack. Otherwise, the resident may have unmet expectations upon arrival to their first “job” situation.

One patient decided to squeak a little bit too loudly in our ED waiting room. He thought that he could jump ahead of other patients by calling 911…from the waiting room. My understanding is that EMS was “on the scene” in just a few seconds. They strapped him to a gurney and brought him through triage. After a thorough evaluation he was sent back out to the waiting room.

Sometimes, the circle is left unbroken.

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Call for Authors and Editors CORD/SAEM Diversity Task Force Cultural Competency Curriculum discussions and teaching content regarding attitudes/assumptions for the physician and patients or relatives and knowledge of health beliefs and customs inclusive of knowledge of provider and of community where applicable. Also included in the teaching cases are aspects of cross-cultural tools and skills including case outcome and disposition. For each of the tier one, two and three sections references are included.

The TF has developed sample chapters and teaching cases which are available for members to use when developing chapters and cases. The Task Force extends an invitation to the CORD and SAEM memberships to develop chapters and teaching cases. The TF currently includes Antoine Kazzi and Marcus Martin as co-chairs and Sheryl Heron, Lynne Richardson, Kumar Alagappan and Ishmael Griffin. Support of the task force is provided by Glenn Hamilton (SAEM Board liaison) and Scott Rudkin (website UCIHS). Yvonne Chan, MD, and Robert Kwon, both of UMDNJ have made major contributions to the developmental efforts.

If you're interested in developing a chapter, please contact Marcus Martin at mlm8n@virginia.edu. If you're interested in developing a chapter on a specific ethnic or racial subgroup, please contact Antoine Kazzi at akazzi@uci.edu. If you're interested in developing a teaching case, please contact Sheryl Heron at sheron@sph.emory.edu. If you're interested in being an editor for the curriculum material, please contact Lynne Richardson at lynne.richardson@mssn.edu.

The CORD/SAEM Diversity Taskforce was organized in 2003 by CORD and SAEM. The objectives are to develop a curriculum to incorporate diversity awareness, cultural competency knowledge and skills for residency training programs and create a website product. The charge to the task force (TF) is to develop a module for EM programs to use to heighten awareness of diverse cultural issues and provide training of health care providers regarding these issues. The TF is developing a "Cultural Competency Curriculum" as an educational resource and a Diversity website has been created for the TF to deposit training materials. Elements of the curriculum include patient/physician, physician/physician, and faculty/resident interaction. The TF is working on a three-tiered approach in developing the curriculum. Tier one content includes educational chapters written or to be written by the CORD and SAEM membership on topics such as interpreter services, physician/patient interaction, LGBT population/physician patient relations, spirituality differences in diverse populations, educating residents to care for multi-cultural patient populations, and culturally competent health care promotions to name a few subjects. Tier two content contains chapters on ethnic/racial groups, which includes comments about beliefs, customs and traditions of each ethnic/racial group and a literature review regarding group-specific health risks and outcomes. Tier three content includes cultural competency teaching cases. Teaching cases contain case presentations specific to a cultural subgroup with instructor versions (questions for

Southeastern Regional SAEM Meeting

8th Annual New England Regional SAEM Meeting

March 19-20, 2004 Chapel Hill, NC

April 28, 2004 Shrewsbury, Massachusetts

The 2004 Southeastern Regional SAEM Meeting will be held in Chapel Hill, North Carolina on March 1920, 2004.

Keynote Speaker: Jeffrey Kline, MD The meeting will take place April 28, 2004, 8:00 a.m.

- 4:00 p.m. at the Hoagland-Pincus Conference Center in Shrewsbury, MA; www.umassmed. edu/conferencecenter/

There will be oral and poster research presentations, round table discussions with leaders in academic Emergency Medicine, keynote presentations by nationally recognized emergency physicians, and time to socialize with colleagues in the southeast.

Please send registration forms to: Gail Kolodziej, Staff Assistant, Department of Emergency Medicine; Porter 5979, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199. Email contact is Gail.Kolodziej@bhs.org

Registration: medical students and residents are particularly encouraged to attend, and receive a discounted registration fee of $50 (medical students) and $75 (residents or nurses). Registration for attending physicians is $125. For assistance with registration and hotel accommodation, contact: Julie Vissers • phone: (866) 924-7929 or (919) 932-6761 • fax: (404) 795-0711 • email jvissers@nc.rr.com. You must reserve your room by February 18, 2004 to get the conference rate for accommodations.

Registration Fees: Faculty = $100; Residents/ Nurses = $50; EMTs/Students = $25. Late fee after April 9, 2004 = add $25. Make checks payable to Baystate Medical Center Emergency Dept.

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SAEM/ACMT Michael P. Spadafora Medical Toxicology Scholarship Dr. Michael P. Spadafora was an academic emergency physician and medical toxicologist who was a member of SAEM and the American College of Medical Toxicology (ACMT) and was dedicated to resident education. After his death in October 1999, donations were directed to SAEM for the establishment of a scholarship fund to encourage Emergency Medicine residents to pursue Medical Toxicology fellowship training. ACMT has graciously agreed to donate matching funds.

Two recipients will be chosen to attend the North American Congress of Clinical Toxicology (NACCT), which will be held September 9-14, 2004 in Seattle. Each award of $1250 will provide funds for travel, meeting registration, meals, and lodging. Any PGY-1 or 2 (or PGY-3 in a 4 year program) in an RRC-EM or AOA approved residency program is eligible for the award. The deadline for application is May 1, 2004. Scholarship recipients will be announced at the annual SAEM and NACCT meetings. Each recipient will also be required to submit a summary of the meeting for publication in the SAEM Newsletter and the ACMT Newsletter. The articles of the inaugural recipients of the Scholarship, Dr. Lindgren and Dr. Ferguson are published in this issue of the Newsletter.

Applications must be submitted electronically to saem@saem.org and include: 1. Curriculum Vitae of applicant 2. Verification of employment and letter of support from the applicant’s program director 3. Letter of nomination from an active member of SAEM and/or ACMT 4. 1-2 page essay describing the applicant’s interest and background in Medical Toxicology

How Moonshine Took Me to Chicago Jeffrey D. Ferguson, MD University of Virginia 2003 Spadafora Scholarship Recipient The 2003 North American Congress of Clinical Toxicology was held in Chicago in September. I was able to attend the meeting thanks to the Michael P. Spadafora Medical Toxicology Scholarship. This was the first year the scholarship, a collaboration of the Society of Academic Emergency Medicine and the American College of Medical Toxicology (ACMT), was awarded.

The CPC competition set the tone of the conference, as cases involving unknown poisons were presented with interjections from clinical toxicologists.

They dissected each case, forming a differential diagnosis and paring down their opinions based on the revealed information. I was familiar with this format from previous CPC conferences, but was amazed by the clinical acumen of the presenters as they outlined their approach to the case, then teased out critical information to decide on the right diagnosis and management. Along with being educational, the presenters did an excellent job at making their presenta-

tions colorful and humorous, drawing a room-filling crowd.

The following four days were filled with lectures and workshops from the leading organizations of clinical toxicology and poison control centers from North America and Europe. These talks presented the most recent data of the profession covering consensus views regarding treatment and management guidelines, toxins that present new occupational dangers, and lessons learned from disasters and events including use of chemical warfare. My personal favorite was the presentation by the Toxicology Historical Society about the infamous moonshiner, Fat Hardy, who was responsible for a large number of methanol poisonings. This brought the conference full circle for me, since much of the reason I was selected for the Spadafora scholarship was my own research into contaminated moonshine.

Over two hundred abstracts were presented during the conference. Along with original clinical and bench 8

research, they included fascinating case presentations and poison control center data. I especially enjoyed the opportunity to talk with presenters to gain different perspectives and ideas regarding their research topics.

While in Chicago, Leslie Dye, the wife of the late Michael Spadafora, hosted this year’s two scholarship winners for lunch. This allowed me to learn more about the physician behind this namesake award. Through his work in emergency medicine, toxicology, and medical education Dr. Spadafora touched the lives of countless patients and physicians. I am certain his legacy will continue to influence the paths of rising physicians for years to come.

Finally, I would like to express my sincerest gratitude to SAEM and ACMT for this scholarship and the opportunity to attend the NACCT. I thoroughly enjoyed my time in Chicago and look forward to continuing my efforts in the fields of emergency medicine and toxicology.

Summary of the Research Symposium at the 2003 North American Congress of Clinical Toxicology Kjell Lindgren MD, MS Hennepin County Medical Center 2003 Spadafora Scholarship Recipient Chicago has been busy this fall. Heartbroken hosts to baseball’s upstart and eventual World Champion Florida Marlins, the “Second City” also hosted the 2003 North American Congress of Clinical Toxicology’s annual meeting. And while this important annual gathering lacked the bombast of Sammy Sosa’s bat, the mystique of a caprine curse, or even national television coverage, the NACCT fielded a terrific line-up of research presentations for its own “fall classic”.

Two hundred and sixty five abstracts were selected for poster and platform presentations, covering all realms of clinical toxicology. With such a large meeting and so many abstracts, one cannot hope to summarize all of the important research being accomplished. As such, this article will simply touch on a few presentations that were especially interesting or clinically pertinent.

The New Coke… Body-stuffers are individuals who spontaneously swallow (often poorly wrapped) cocaine in an attempt to hide evidence, with the unguarded optimism that everything will come out OK in the end. While the literature does not define a set observation period for the acute presentation of these patients, many clinical centers will watch the asymptomatic patient for 6 hours before discharging them to their own care. Yao et al. provided an account of a 26 year old male who presented 90 minutes after ingesting 5-8 packets of rock cocaine. The patient presented with normal vital signs, was treated with activated charcoal and polyethylene glycol, and remained well until 7.5 hours post-ingestion when he became symptomatic with hypertension, tachycardia, and seizures.

This case suggests that 8 to 10 hours may be more appropriate, that further research into this issue is needed, and that aluminum foil does not have a waterproof seal.

To check or not to check… Patients presenting to the ED with overdose in the setting of a suicide attempt will often have both a serum salicylate and acetaminophen level checked.

While salicylate levels are easily obtained, there is still some controversy as to the appropriate use of the test. Wood et al. performed an observational retrospective review of 726 patient charts and lab records. They found that a positive history of salicylate ingestion was 81% sensitive, with a positive predictive value of 79%. More importantly, a negative history of salicylate ingestion had a negative predictive value of 98%. While this study had some important limitations (retrospective, selection bias, and small n with possible type II error), it does help affirm the practice of those who believe that a salicylate level is unnecessary in the conscious, asymptomatic overdose patient who denies ASA ingestion.

And now for something completely different…Escitalopram (Lexapro), an enantiomer of the racemic SSRI citalopram (Celexa), was introduced to the US market about a year ago. Because of its novelty, little was known about this drug’s side effects and activity in overdose.

Wiegand et al. presented a case of serotonin syndrome in a 75-year-old male who had just started SSRI monotherapy for depression. The patient presented with one day of altered mental status, fever, and new onset upper extremity tremor.

The patient had been taking escitalopram 10mg PO for two days, had never used an SSRI before, and was taking no other

serotonergic medications. While the patient’s urine showed citalopram, the remainder of lab tests and imaging were unremarkable. Escitalopram was discontinued on admission and the patient was asymptomatic by day 3. This case should remind us to keep serotonin syndrome in our differential diagnosis – even in the setting of SSRI monotherapy at therapeutic doses.

What’s good for the goose, is good for the gosling…

Sulfonylurea overdose can result in resistant hypoglycemia from the stimulation of pancreatic b-cells and subsequent insulin release. Management of sulfonylurea overdose typically involves 10% dextrose IV infusion, frequent blood glucose checks, and 50% dextrose IV boluses as needed. Rebound hypoglycemia from dextrose infusion may require octreotide to suppress insulin release from b-cells. Kent et al. reported a case in which octreotide was used in managing resistant hypoglycemia in a 16 month old child. Despite IV dextrose infusion and several boluses of 50% dextrose, the patient continued to have rebound hypoglycemia. Octreotide 10mg IV over 15 minutes was used twice over the course of the patient’s treatment with good effect. The patient was discharged home 24 hours post ingestion with no sequelae. This case serves to remind us that octreotide may be an effective therapy for sulfonylurea overdose in both adult and pediatric patients.

Make like glue and stick around… Buproprion is an atypical antidepressant with norepinephrine, serotonin, and dopamine activity used in smoking cessation and depression. Seizures have been seen in overdose with both the immediate and sustained release forms. Many clinical centers will observe these patients for 12 hours prior to disposition. Goldstein et al. presented a case series that identified four patients that had delayed onset of seizures. Two patients had their initial seizure after 12 hours of observation. One patient’s first seizure occurred between 12 and 18 hours, the second patient’s initial seizure occurred at about 38 hours. This study suggests that the current practice of charcoal and 12 hours of observation may be inadequate.

I thought you said your dog did not bite! That is not my dog…Quetiapine (Seroquel) is an atypical antipsychotic with dopamine and serotonin activity that is structurally similar to the tricyclic class of antidepressants. Caravati et al. conducted in vitro evaluation of quetiapine’s potential to cross react with TCA immunoassays. They found significant cross-reactivity with both the quantitative and two qualitative assays tested. This study should remind us of the fallibility of our lab tests and that our clinical suspicions should direct lab investigation and not the other way around.

In conclusion. For those of you who were unable to attend the meeting in Chicago, I hope this article provides some sense of the interesting topics that were presented. The symposium provided an important outlet for cutting edge research and practical presentations and I hope you will consider attending this meeting in the future.

Finally, I would like to thank the American College of Medical Toxicology, the Society for Academic Emergency Medicine, and Dr. Leslie Dye for the opportunity to attend this meeting.

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Academic Emergency Medicine and the “Tragedy of the Commons” Roger J. Lewis, MD, PhD Harbor-UCLA Medical Center SAEM Past President This manuscript is based on the 2003 President’s Address delivered by Dr. Lewis at the 2003 SAEM Annual Meeting in Boston, Massachusetts.

The “Tragedy of the Commons” Defined Occasionally, one comes across an idea which, although old, can lead to greater insight into current problems.

The concept of the “Tragedy of the Commons” is such an idea. To define the Tragedy of the Commons, one can begin by examining each word. The term “tragedy,” according to the second definition in Webster’s 7th New Collegiate Dictionary, is “a serious drama typically describing a conflict between the protagonist and a superior force (as destiny) and having a sorrowful or disastrous conclusion…”. The word “tragedy,” when used to describe a story or legend, is not meant to imply only a sequence of unfortunate or painful events but, furthermore, to imply a certain natural progression or inevitableness of those events.

Also according to Webster’s, the fifth definition of a “common” is “a piece of land subject to common use: as a: undivided land used especially for pasture (or) b: a public open area in a municipality…”. In old England, the term “commons” referred to an area of land which was used for grazing livestock. It was a shared common resource used for the benefit of all. In contrast, however, each shepherd owned their own livestock, and benefited only from the livestock within their herd. In modern times, the term “commons” also applies to any area of public use which is open to all.

The Tragedy of the Commons was first described by William Forester Lloyd in 1833, but placed into modern context by population biologist Garrett Hardin, in an essay published in 1968 in the journal Science1 and updated in 1998.2 The Tragedy of the Commons is a principle that applies in numerous healthcare, academic, and other settings. It is one of those rare concepts that, once understood, is found to be relevant in more and more areas of our daily lives. 3-6 In its original context, the Tragedy of the Commons refers to the fate of shared pasture land. The old English system of sharing pasture space seems inherently fair, and our intuition might be that this system would maximize the

benefit of the common space for all.

There is appealing equality and simplicity in the commons. Each shepherd finds himself in the same position—no one owns the land or has more or less claim to it.

Every year, each herdsmen seeks to improve his wealth by deciding whether to graze additional, fewer, or the same number of animals. Of course the commons has a fixed “carrying capacity” and, as the number of animals grazed on it increases and approaches this limit, the average weight gain of each animal decreases. From the point of view of each herdsman, the decision to add one more animal to his herd yields almost the benefit of one of his current animals. It is true that each animal may be slightly leaner because of the additional competition, but virtually all of the benefit of one animal will be realized.

The benefits of adding an animal is neither shared with others nor diluted. In contrast, the negative effect on the commons is distributed among all herds and all herders, and is thus relatively small from the point of view of each individual herder. Thus, any rational herder will conclude that it is in their best interest to add additional animals to their herd each year.

The tragedy occurs because each herder finds himself in exactly the same situation, and thus each herder adds more and more animals to his herd.

Eventually the commons is overgrazed, and all of the animals become weak, underweight, and are susceptible to disease. This leads to the collapse of the herds and the downfall of the herders. A fundamental asymmetry—complete interest in the size of one’s own herd, but only an indirect and partial interest in the well-being of the commons itself, leads to this tragedy. This sequence of events, which results in the destruction of not only the commons, but also of the herds and the herders, is an inevitable result of the system that governs the use of the commons—hence the tragedy.

What are the key elements of the tragedy of the commons? First is the existence of a shared but limited

resource, vitally important to the life of those who share it. Second is the desire of each participant to have more of the resource than currently allocated to them. Finally, there is equal and unfettered access—a lack of external control.

For example, there is no governing agency which sets limits on the number of sheep each herder may graze on the commons. The outcome of this combination of factors is sometimes summarized as “freedom in a commons brings ruin to all.” Importantly, these elements occur frequently in many settings, sometimes even intentionally, recreating the tragedy. The three elements of the tragedy, when in place, lead rational people to make decisions that ultimately destroy their common resource.

Have we learned the lessons taught by the tragedy of the commons?

Consider the fact that cattlemen in the United States still constantly pressure authorities to allow larger herds to graze on federal land. Or the fact that many fishermen still believe in the “freedom of the seas” and the “inexhaustible resources of the oceans.” While we might criticize these groups for failing to heed lessons of the past, we also must consider the current state of emergency healthcare and the current state of academic emergency medicine. In the rest of this commentary, I would like to point out some situations which partially or completely replicate the tragedy of the commons, but from within the world of emergency medicine.

Emergency Medical Care as a Commons The emergency medical services (EMS) system is a resource that, by law, is available to all without restriction. It is also a limited resource, as both equipment and personnel are limited by budgetary constraints and competing priorities of local, county, and state governments. Furthermore, there is generally no negative incentive in place to limit use of the EMS system for nonemergency care. Since each of the key elements of the Tragedy of the Commons are recreated in our EMS system, it is not surprising that we see (continued on next page)

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“Tragedy of the Commons”

(Continued)

an EMS system that is often stretched to capacity, used as an expensive taxi service, or that there is a subset of users who utilize the system far more than others.

Just as with the overgrazing of pasture lands, this dynamic leads to a degradation in the quality of the common resource. This degradation is manifested as reduced availability of EMS units, long response times, provider “burnout,” and the institution of compensatory changes (e.g., tiered response).

Each of these factors reduces the overall quality of the resource—a deterioration of the commons.

The emergency care provided in emergency departments across the country is also an example of a commons. It is a resource which is valuable to all, especially in times of unexpected need, and under EMTALA/COBRA legislation it is available to all without restriction or consideration of ability to pay. 7 For many members of our society the emergency department (ED) is their only access to needed medical care, and they often need more care than they currently receive. In addition, there are little or no incentives to limit use. The resulting behavior, on the part of a subset of users, is to use the ED as their primary source of care, to use the ED for non-emergency care, and to fail to identify and access other sources of primary care that they may have available to them. It is important to note that these behaviors are the logical and inevitable consequence of creating a commons—they are not the result of any lack of moral character or judgment on the part of individuals. In fact, these individuals are appropriately reacting to the healthcare system we have created, in which there is only one source of medical care that is open to all without restriction or limit. The irony here, of course, is that primary care in our country is a closely managed resource, whereas emergency care is purposely unmanaged.

As is well known to all emergency physicians, our emergency departments are being “overgrazed.” This is manifested by overcrowded waiting rooms and EDs, frustration on the part of both physician and nurse providers, physician “burnout,” and decreased quality and timeliness of care. It is fundamentally irrational for academic emergency physicians to bear witness to the continual degradation of the commons that is

emergency healthcare while, simultaneously, arguing vehemently that this precious resource remain unmanaged.

Unfortunately, that is exactly the position of many organizations and leaders within the field of emergency medicine.

Now consider the moral and equity arguments in support of universal health insurance in our country. The total public funds to be spent on healthcare is essentially limited by external economic and political factors, creating a sort of economic commons. Under our current system, of course, many members of our society have essentially no access to health insurance. This constitutes de facto management of the common resource. Ironically, arguments in favor of universal health insurance, to the extent that they fail to increase the size of the commons by creating new sources of funding, are arguments in favor of creating the key elements of the tragedy. Given the limited resources, this tragedy would consist of universal health coverage which, over time, is slowly degraded in its scope and value, and in its ability to ensure quality healthcare for all. The initial stages in this process have already been seen in some settings, in which a large segment of the population is “covered” using public funds, but the level of reimbursement is so low that skilled providers will not voluntarily provide care. With this approach, we may create an illusion of universal healthcare, but that may be all.

Research Development and Training in Academic Emergency Medicine I will now switch my focus from emergency healthcare to the processes required to establish a productive research program in an academic emergency department. I will begin by discussing a cycle of research productivity, and then identify relevant commons and consider how we manage those resources.

In the figure, different stages in the development of a research program, and their relationships, are shown. A fundamental first step is the research training of one or more (hopefully more) core investigators.

Without such research training, it is unlikely that an investigator can initiate, obtain funding for, and complete research projects of the quality and scope necessary to garner recognition for the department as a whole. Solid research training leads to both an improved quality and increased

quantity of research in a department, which in turn leads to local recognition for the department, usually from inside the medical school or university. Such internal recognition leads to improved opportunities for local funding and for academic recognition. With the additional resources available from local funding and improved opportunities for collaboration associated with recognition locally, investigators in the department are able to initiate and complete projects of a quality and scope that yield recognition nationally. National recognition leads to opportunities for extramural funding, as well as for substantive collaboration outside of one’s own institution. These opportunities, in turn, ultimately yield other research resources and infrastructure through extramural grants and/or national collaborations.

The last link in the cycle, and perhaps the most important, is the relationship between a nationally-recognized research program and the opportunity to provide research training. This link occurs both because of the relative ease with which appropriate candidates can be recruited if one has a national reputation, as well as the increased chance of obtaining extramural funding for career development and training grants when the local mentors have demonstrated productivity. Thus, there can be a complete, self perpetuating cycle of research productivity and development, but it must begin with a core group of well-trained investigators.

The table shows key elements which are required by a trainee to acquire essential research skills—the first step in development of a research program.

In the following I will focus on two of these key elements: (1) the availability of a qualified and effective mentor; and (2) sufficient protected time to develop a set of research skills.

Although specific data are difficult to obtain, it is widely believed that a good mentor is one of the most important predictors of long-term research success on the part of the trainee. This is especially true for trainees with little formal research training, as is typical of young investigators in emergency medicine whose primary post-college training is focused on medicine (e.g., an MD degree and residency) rather than on research activities. Accordingly, the qualifications of the mentor, the mentor’s track record in research training, and the quality of the mentor-trainee (continued on next page)

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“Tragedy of the Commons”

(Continued)

relationship are all important factors considered during the evaluation of fellowship and research training grant applications.

From the point of view of a young researcher, the mentor is a type of commons. A good mentor is extremely valuable to all trainees wishing to enhance their research skills and productivity.

The mentor is valuable unless, of course, they must be shared with too many other trainees or have too many other research, clinical, or administrative responsibilities. If the mentor is spread too “thin,” regardless of their qualifications and intent, they will be of little use to their trainees. One way this issue can be addressed, however, is to increase the “size” of the mentor-commons, by recognizing that good mentors can often be found outside of emergency medicine. At institutions in which insufficient mentoring capacity is available within emergency medicine, one must be willing to identify and cultivate relationships with outside mentors.

Given that mentors are a valuable and limited resource, it is ironic that we sometimes create a “tragedy” by insisting that all emergency medicine residents perform research. This practice often leads to the mentor’s time being spread so thin that they are of little use to the few residents who truly wish to pursue a research career, or to the junior faculty within their department who desperately need their assistance. In essence, we recreate the Tragedy of the Commons and this is manifested by a degradation in the quality of mentoring for all who need it.

In virtually all departments of emergency medicine, non-clinical, nonadministrative time is also a type of commons. Such protected time is critically important to the young investigator wishing to develop research skills and to establish a track record of productivity.

In fact, such protected time is critical for even the most experienced investigators who wish to remain productive. If the non-clinical, non-administrative time is spread evenly among all faculty, however, in most settings the absolute quantity of such time will be so limited that it will be insufficient to support the careerdevelopment phase of a young investigator. In other words, even with the current size of our “herds” of faculty members (which are necessary to fulfill our clinical and clinical teaching responsibilities) the commons of protected time is

insufficient to support the development of a research career if distributed equally.

As a field, how good are we at research training and research career development? In 1999, Blanda et al published a study based on a survey of self-identified research directors in emergency medicine.8 That survey showed that 53% of research directors were junior faculty (at the instructor or assistant professor level), and that the median length of time spent in the position was three years. Furthermore, approximately one-third of research directors reported no publications in the prior three years. Only 27% of research directors had a research degree and 21% had completed a research fellowship, although the duration of these research fellowships was unclear. 8 Assuming that the research director is usually the research mentor in each department, it would appear that, as a specialty, we have been largely unsuccessful in creating an adequate group of mentors (the commons) for our young trainees.

It is instructive to contrast the research training and productivity of research directors in emergency medicine with the minimum training requirements for trainees suggested in the guidelines for institutional fellowship grants supported by the National Research Service Awards (NRSA) program. In the latter case it is stated that “…postdoctoral trainees should agree to engage in at least 2 years of research, research training, or comparable activities beginning at the time of appointment since the duration of training has been shown to be strongly correlated with post-training research activity.”9 In other words, the national standard, based on actual data regarding subsequent research success, implies a higher level of training for fellows than we are able to document for the majority of research directors in emergency medicine. Thus, for most departments to be able to initiate the cycle of research training and development shown in the figure, a substantial and sustained investment in our research trainees in the form of protected time and resources, must be made.

Avoiding the Tragedy of the Commons How do we avoid the tragedy of the commons and maximize the benefit of a

common resource for all?

Most approaches attempt to alter one of the key elements of the tragedy so that the underlying dynamic is never realized.

Approaches include converting common resources to private property, eliminating the commons altogether, or regulation of the use or active allocation of common resources—restricting personal freedom. Such approaches can be summarized as “mutual coercion, mutually agreed upon.” In addition, a number of authors have identified other social mechanisms that, in specific cases, appear to prevent the tragedy.

While mutually agreed upon limitations may prevent destruction of the commons, in some cases the resources will be so dilute as to be of little use (e.g., protected time). Thus, the maximum benefit for the whole group, or an entire academic department, may be achieved only with unequal allocation of a scarce resource. This is unsettling to many who implicitly assume that an equal allocation of resources is optimal.

There are a number of common barriers to any solution to the Tragedy of the Commons. These barriers include devotion to individual freedoms, namely, a belief that all should have equal and unfettered access to any valuable resource. In many settings, we seem to believe that equality requires freedom— that external controls are inherently unfair. In many settings there is also a distrust of external regulation.

Furthermore, many believe in simplistic defenses of the right to equal access to commons. By simplistic, I mean without regard to an analysis of the effect of this free and unfettered access on the commons itself. Lastly, many believe in the fundamental value of equality, independent of the consequences of such equality. A defense of right to access, however, without explicit consideration of the consequences, is shortsighted and often misleading.

What solutions have been found to the tragedy? Solutions include limits on fishing in international waters, the use of parking meters, and international limits on air pollution. Examples in the healthcare setting are more difficult to find, although systems for the equitable distribution of solid organs for transplantation is one example.

Focusing back on the field of emergency medicine, what are possible solutions to the tragedies that we have created? One approach to avoiding the (continued on page 20)

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Western Regional SAEM Meeting

4th Annual New York State Regional SAEM Meeting

April 3-4, 2004 Oakland, CA

March 31, 2004; 8:00 am-2:00 pm Hosted By:

Highland General Hospital – Alameda County Medical Center, Department of Emergency Medicine

Location:

Waterfront Plaza Hotel, Jack London Square 10 Washington Street Oakland, CA 94607

Contact:

Robert Rodriguez, MD, IRB Chairman Highland General Hospital Department of Emergency Medicine 1411 E. 31st Street Oakland, CA 94602 rrodriguez@hghed.com

Hosted by: St. Luke’s-Roosevelt Hospital Center, Department of Emergency Medicine Location: Lerner Hall, Morningside Campus, Columbia University, 114th Street and Broadway Keynote Speaker: Glenn Hamilton, MD, Wright State University Contact: Theodore C. Bania, MD, MS at Roosevelt Hospital, 1000 10th Ave., Department of Emergency Medicine, Room GE01, New York, NY 10019 or toxtod@aol.com

Solicitation of Readings for ABEM Future Lifelong Learning and Self-Assessment Test Disorders and Cutaneous Disorders. ABEM will select 50% of the readings for the 2005 LLSA test from these two designated areas, while the remaining 50% of test content will be drawn from the remaining content areas of the EM Model “Listing of Conditions.”

A cornerstone of ABEM’s new EMCC program is the concept of Lifelong Learning and Self-Assessment (LLSA). The primary goal of LLSA is to promote continuous learning on the part of ABEM diplomates. ABEM will facilitate this learning within the context of LLSA by identifying an annual set of readings to guide diplomates in self-study of recent Emergency Medicine (EM) literature.

ABEM has sought to involve the EM community-at-large in the LLSA process by inviting EM organizations and ABEM diplomates to make suggestions for readings to the ABEM Board of Directors. For the 2005 LLSA to be developed next year the Board received over 125 suggestions collectively from ACEP, SAEM, CORD, AAEM, and a number of individual ABEM diplomates.

How to Submit Recommendations for LLSA Readings For each reference submitted, ABEM must receive the following two items: 1. Complete an LLSA Form for each reference that you recommend to the Board. Be sure to provide all requested information for each reference, including the article title completely written out, the journal name, etc. Do not use abbreviations. Do not alter the form in any way, except to add the requested information in the space provided. The LLSA Reference Form is available from ABEM and may also be downloaded as an MS Word document from the ABEM website. The form can be computer-printed or typewritten.

Submission Criteria for LLSA Readings The Board has determined that readings used for the LLSA tests should meet the following criteria: 1. Focus on recent advances or current clinical knowledge in Emergency Medicine; 2. Be clinically oriented in content; 3. Be drawn from peer-reviewed EM journals, peer-reviewed journals from related primary specialty fields, textbook chapters, or updated practice guidelines; 4. Be published in printed or electronic form within the immediate five years preceding the LLSA test in which it will be used; 5. Relate to either the designated content areas for a given year (50%), or to the remaining content areas (50%) of the EM Model “Listing of Conditions.”

2. Provide one paper copy of the article, chapter or other text for which you have submitted a reference must be mailed or faxed to ABEM in order to be considered for inclusion.

Electronic copies of references cannot be accepted due to copyright restrictions.

References received by June 1, 2004, will be considered for inclusion in the 2005 LLSA module. Materials submitted after that date may be considered for future LLSA tests.

Recommendations may be submitted via fax to (517) 3323943 or mail to LLSA References, American Board of Emergency Medicine, 3000 Coolidge Road, East Lansing, MI 48823.

If you have specific questions or comments contact Timothy J. Dalton, Examination and Evaluation Project Specialist, at (517) 332-4800.

Content of LLSA Test in 2006 Although readings for the first LLSA test in 2004 have already been selected, the Board welcomes reference suggestions for future LLSA tests from the larger EM community on an ongoing basis.

Currently, ABEM is soliciting readings for the 2005 LLSA test, for which the designated content areas will be Traumatic 13

ACADEMIC RESIDENT News and Information for Residents Interested in Academic Emergency Medicine Edited by the SAEM GME Committee

ABEM Certification and Recertification Update Trevor J. Mills, MD, MPH Charity Hospital For the GME Committee “The fall of Zion to the Machines” mumbled the resident as I prepared to give our program’s annual lecture on “how to prepare for the ABEM boards,” including the new Emergency Medicine Continuous Certification (EMCC).

Disregarding the popular culture metaphor, I went on to explain how the new and improved ABEM exam format will be more interesting, educational and ultimately better, for adult learners and EM as a specialty.

It has been said “to understand the future, you must understand the past.” The “official” history of the ABEM boards started with recognition by the American Board of Medical Specialties in September of 1979. The original qualifying pathways for the ABEM exam included either successful residency training, or clinical experience (5 years and 5000 hours). As EM solidified its standing as a prominent medical specialty, and residency programs increased in their numbers and size, the practice path was closed in 1988.

The current pathway to ABEM certification (following successful completion of residency) consists of a written exam and an oral exam. In the past, recertification could be obtained by either repeating a modified written exam or by re-taking the oral exam.

The initial post-residency exams will not change under the current EMCC model. The written certification is, and will remain a 6.5-hour test, which contains approximately 335 single-best answer multiple-choice questions. Between 10-15% of the questions include a visual stimulus. The oral certification examination is, and will remain, a half-day exam that includes 7 simulated patient encounters: 5 single patient and 2 multiple-patient encounters.

Over the last 23 years pass rates for the written boards (both residency trained and clinical pathway) have ranged from 52-78%. However, when focusing on EM residency trained individuals, the pass rate is significantly higher (8891%). A similar pattern is seen in the oral board results, when looking at both pathways, examinees have a 57-88% pass rate, however, residency trained individuals have an 86-97% pass rate.

In this modern era, with the “rise of the machines” (computers) the opportunity for more frequent, relevant and current re-certification methods has become available. This coupled with the newest concepts in adult learning may have stimulated the move to EMCC. The EMCC contains 4 components: Professional Standing, Lifelong Learning and Self Assessment (LLSA), Assessment of Cognitive Expertise and Assessment of Practice Performance.

Professional Standing basically boils down to having an active US or Canadian medical license in good standing.

LLSA is where the revolution begins. The lifelong learning portion consists of 20 readings posted on the ABEM website each year. The readings are organized by topic and year (see Table 1). The readings will be a mix of original research and review topics pulled from a variety of sources.

Table 1 Year

Topic

2004

Thoracic-Respiratory, Immune System, Musculoskeletal

2005

Nervous System, Toxicology

2006

Traumatic, Cutaneous

2007

Signs, Symptoms, and Presentation, Psychobehavioral

2008

Procedures and Skills, Environmental

2009

Cardiovascular, Hematological

2010

Abdominal and Gastrointestinal, Other Components of Practice

2011

HEENT, Endocrine, Metabolic, Nutritional, Renal and GU

2012

Systemic Infectious Disorders, OB/GYN

The self-assessment portion of the LLSA consists of a yearly 40-question test based on the lifelong learning articles. These questions are accessed from your home computer, at your leisure. You will have three chances to pass each yearly self-assessment exam.

The assessment of cognitive expertise is to be tested by the ConCert exam. This exam will take place every ten years, following your original board certification date. In essence this takes the place of the current recertification written boards. However, the ConCert will incorporate both traditional EM core knowledge topics and questions from the LLSA yearly tests. Unlike the LLSA yearly tests, you will not be able to take the ConCert at home, rather you will have to sign up for a half-day at a local computer testing center.

14

The final component of the EMCC is the assessment of practice performance. This “yet to be determined” evaluation tool will focus on practice improvement and will have several ways to meet requirements. As the details are being worked on, the anticipated start date for this is 2007.

So, now that we have a system that promotes life long learning after residency, what do we do with it during residency? There are multiple ways to incorporate the EMCC into residency training. The LLSA articles could be presented during a dedicated lecture format on a monthly or quarterly basis. Alternatively, they could be integrated into the weekly resident lecture series by specific topic, eg., musculoskeletal into an ortho lecture, etc.

Or, they could be incorporated into a journal club format.

For those individuals who prefer to study alone, or are past the blissful years of residency training, the individual articles can be downloaded for self study from the official ABEM website (www.abem.org) and can be found on several unofficial websites (www.emedhome.com).

Several Board Review Courses also incorporate the articles into their course material.

In summary, residency training, unchanged. Written and Oral boards after residency training, unchanged.

Once you have your board certification, yearly tests can be taken from your computer at home. Every ten years, a written board exam based on yearly readings, taken at your local computer center. Starting in 2007, there will be some sort of practice performance evaluation.

The Resident Member of the SAEM Board of Directors: Seeing Past ‘The Meeting’ Valerie De Maio, MD University of North Carolina, Chapel Hill SAEM Board of Directors Having been elected to the SAEM Board of Directors last May was an honor to say the least. Little did I know how illuminating the experience would be.

I have been a member of SAEM for seven years. As I knew it, SAEM was this great Annual Meeting: a yearly get-together where we would share our research, make new alliances, and catch up with old acquaintances.

In fact, the only two times of the year I really gave SAEM much thought were during the holiday season (the infamous January abstract rush), and in the spring as I prepared slides for the May meeting. Now, having served on the Board, I realize that SAEM means so much more. SAEM is not just a meeting (though it is the highlight of our academic year), nor is it simply a group of researchers and educators.

SAEM is a collective membership of workers and visionaries - forces of change and the future of our profession.

The role of the SAEM Board of Directors is to organize the membership, guide their initiatives, and oversee the mission to promote academic emergency medicine by advancing research and education. Board members review issues, proposals, manuscripts, and activities of the membership, committees, task forces, and interest groups. I have learned that our membership is extremely produc-

tive in this regard. As such, the bulk of the work of the Board is largely carried out through email exchange (I have gained a healthy new respect for email). Monthly conference calls and meetings are the forum for discussion and resolution of some of the more complex items and oftentimes the springboard for new initiatives.

SAEM programs are numerous but I have come to realize that perhaps there are just three areas of focus that serve to further our mission. First, one of the greatest marks of SAEM is the emphasis on its youngest members, encouraging those who have embarked upon a career in emergency medicine toward leadership and academic roles. All one must do is look to the SAEM website to find the abundant resources and opportunities available to the young EM enthusiast.

Second, SAEM strongly values mentoring and encourages these relationships at all levels, from the undifferentiated medical student contemplating a career in EM to the seasoned faculty member seeking promotion or tenure. When I searched the SAEM website for the term ‘mentor’, 224 references were identified. The virtual advisors group, academic career guide, and faculty development website are only a few examples. Finally, SAEM is focused on the future.

Significant thought is put to anticipating the needs of our growing special-

15

ty. Presently SAEM is evaluating mechanisms to increase research funding. SAEM has also partnered with other EM organizations to fund the dissemination of the Institutes of Medicine study on the future of emergency care, which holds promise to be the biggest thing to happen to our specialty since the 1994 Macy Report.

Having this look at the inner workings of our academic society has furthered my understanding of what it means to be a true EM academician.

When I look around the table at the other members of the Board, I see my future. Board members come in all shapes and sizes: their experiences are varied and their expertise wideranging. Each member has his or her own unique approach to dealing with the issues. The common thread is the enthusiasm with which they set out to meet the mission. As resident member, I am in a unique position to gather from this medley of mentors to develop my own leadership style. I hope that this will allow me to contribute more effectively to the specialty in years to come. Appreciating the currency of the SAEM mission, I now realize that there may be anticipated dividends in having a resident participate as a member of the board.

As always, I look forward to seeing you all at The Meeting.

Principal Investigator Project Grants (61) Arzbaecher, Robert Baumlin, Kevin Becker, Lance

Bernstein, Edward

Bijur, Polly Biros, Michelle Boyer, Edward Callaway, Clifton

Crain, Ellen Daya, Mohamud D'onofrio, Gail Feldman, James

Fleisher, Gary Gesell, Laurie Beth Gorelick, Marc Green, Gary

Greenes, David Hoffman, Stuart Howes, David Jauch, Edward

Kelen, Gabor Kellermann, Arthur Kline, Jeffrey

Krause, Gary Lach, Thomas Li, Guohua

Lurie, Keith McCarthy, Melissa

Award Title Subcutaneous Monitor/Alarm For Cardiac Arrest Prehospital Stroke Care: strengthening the chain 1. Optimizing Heart And Brain Cooling During Cardiac Arrest 2. Apoptosis And Oxidants After Murine Cardiac Arrest 3. Impacts Of Alcohol / Fatigue On Paramedic Skills 1. A Randomized Trial of the Brief Negotiated Interview.

2. Ethnic and Racial Differences Among Cocaine and Heroin Users.

Racial And Ethnic Disparities In Acute Pain Control Disparities In Emergency Health Care Relationship Between The Internet And Illicit Drug Use 1. Hypothermia And Gene Expression After Cardiac Arrest 2. Brain Ischemia And Map Kinase Activation Team Targeting The Environment And Asthma Management Public Access Defibrillation Trial In Portland, Oregon Emergency Physician Brief Interventions For Alcohol 1. Testing Zafirlukast (Accolate) In Subjects With Asthma Exacerbations 2. Sestamibi For Emergency Triage For Suspected Cardiac Ischemia Trial Research Training In Pediatric Emergency Medicine Complementary Hyperbaric Oxygen for Brain Radionecrosis PEAT: Pediatric Emergency Assessment Tool 1. Coronary Thrombosis And Risk In The Emergency Department 2. Training of hospital staff for disasters Automated Lab Test Follow-Up To Reduce Medical Errors Effects Of Dihydroepiandrosterone On Brain Injury A Rct Of Computer Screening For Domestic Violence Functional Proteomics Identification of Serum Proteins Associated with Intracerebral Hemorrhage Following Thrombolytic and Antiplatelet Therapy for Acute Ischemic Stroke Surge Capacity in Disasters Progesterone Treatment Of Blunt Traumatic Brain Injury 1. Pretest Probability Assessment For Pulmonary Embolism 2. Surrogate Markers for Severe Pulmonary Embolism Suppression Of Protein Synthesis In Reperfused Brain Lifebelt CPR: Combined Thoracic And Sternal Compression 1. Alcohol And General Aviation 2. Pilot Aging And Aviation Safety Impedance Threshold Valve For Improving Standard CPR Pediatric Injury

Institution

Award Number

AJ Medical Engineering

5R43HL069608-02

Mt. Sinai School of Medicine University of Chicago

Project End Date 5/31/2004 2003

1. 1R01HL067630-01A1

1. 7/31/2007

2. 1R01HL071734-01

2. 7/31/2006

3. 1R03HS011750-01

3. 9/29/2003

1. R01DA10792-06 A1

1. 11/30/2003

2. R01DA10792-05 S1

2. 11/30/2003

Yeshiva University

1R01HS013924-01

6/30/2006

Society for Academic Emergency Medicine University of Massachusetts

1R13HS014030-01

5/14/2004

5R21DA014929-03

8/31/2004

University of Pittsburgh

1. 5R01NS046073-02

1. 6/30/2006

2. 5K02NS002112-05

2. 6/30/2006

5U01AI039900-05

7/31/2003

Boston University

Yeshiva University Oregon Health Sciences University

2006

Yale University

5R01AA012417-02

Boston University

1. 5M01RR000533-350326

7/31/2004

Awarding Institution National Heart, Lung, and Blood Institute American Heart Association 1. National Heart, Lung, and Blood Institute 2. National Heart, Lung, and Blood Institute 3. Agency for Healthcare Research and Quality National Institute on Alcohol Abuse and Alcoholism

Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality National Institute on Drug Abuse National Institute of Neurological Disorders and Stroke

National Institute of Allergy and Infectious Diseases National Heart, Lung, and Blood Institute National Institute on Alcohol Abuse and Alcoholism National Center for Research Resources

2. 5M01RR000533-350317 Children's Hospital (Boston)

5T32HD040128-03

4/30/2006

University of Cincinnati

1R21CA102497-01

8/31/2005

Medical College of Wisconsin

5R03HS011395-02

9/29/2003

Johns Hopkins University

1. 5R01HL069746-02 2. U-01

8/31/2004

Children's Hospital (Boston)

1R03HS011711-01A1

9/29/2004

Emory University

5R03HD040295-02

3/31/2004

University of Chicago

5R01HS011096-03

8/31/2003

University of Cincinnati

5P50NS44283-02

8/2007

Johns Hopkins University

U-01

Emory University

5R01NS039097-03

Carolinas Medical Center

1. 1R41HL074415-01

7/31/2004

2. 1RO1HL07438401

12/31/2003

Wayne State University

5R01NS033196-08

12/31/2003

Deca-Medics

1R41HL071378-01A1

4/30/2004

1. 5R01AA009963-10

1. 6/30/2004

Johns Hopkins University CPR X Llc

2. 2R01AG013642-06 2R44HL065851-02

2. 6/30/2008 1/31/2004

Johns Hopkins University

R-01

16

National Institute of Child Health and Human Development National Cancer Institute, National Institutes of Health Agency for Healthcare Research and Quality 1. National Heart, Lung, and Blood Institute 2. Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality National Institute of Child Health and Human Development Agency for Healthcare Research and Quality National Institute of Neurological Disorders and Stroke

Agency for Healthcare Research and Quality National Institute of Neurological Disorders and Stroke National Heart, Lung, and Blood Institute

National Institute of Neurological Disorders and Stroke National Heart, Lung, and Blood Institute 1. National Institute on Alcohol Abuse and Alcoholism 2. National Institute on Aging National Heart, Lung, and Blood Institute Agency for Healthcare Research and Quality

Principal Investigator Ma, Xin-Liang Maitra, Subir Mandl, Kenneth Markenson, David Mosesso, Vince Neumar, Robert Olson, James

Regan, Raymond Richardson, Lynne Rothman, Richard

Segal, Gershon Smith, Sharon Stein, Donald

Sullivan, Jonathon Terndrup, Thomas

Thom, Stephen Vanden Hoek, Terry Warman, Matthew Gregory, Jay Wears, Robert

Willis, John Wright, Robert

Yealy, Donald Young, Kelly Zink, Brian

Award Title Peroxynitrite In Cardiac Ischemia/ Reperfusion Injury Glu6pase And 6p2k/Fbase Gene Regulation In Sepsis Disease Surveillance In Real Time: Geotemporal Methods Pediatric Disaster Preparedness And Response Conference Public Access Defibrillation Trial Calpain-Mediated Injury In Post-Ischemic Neurons Mechanisms Of Cellular Taurine Transport In Brain Edema Effect Of Inducible Antioxidants On Hemoglobin Toxicity Research Without Consent: The Community Perspective 1. Evaluation Of Febrile Iv Drug Users-Guidelines For Emergency Management 2. Development of Diagnostic Platforms for Bioterrorism Events Endotoxin Assay For Analysis Of Septicemia Damage Social Support And Education In Asthma Follow-Up 1. The Effects Of Progesterone And Its Metabolites On Tbi 2. Progesterone After Traumatic Brain Injury Cell Survival In Brain Reperfusion

Institution

Award Number

Project End Date

Thomas Jefferson University

5R01HL063828-03

5/31/2004

State University New York Stony Brook Children's Hospital (Boston)

5R01GM058047-03

7/31/2004

1R01LM007677-01

6/30/2006

Columbia University

1R13HS013855-01

9/29/2003

University of Pittsburgh

12/2004 4/30/2005

Wright State University

5R01NS037485-03

3/31/2004

Thomas Jefferson University

1R01NS042273-01A1

11/30/2006

Mount Sinai School of Medicine of NYU 1. Johns Hopkins University 2. Johns Hopkins University/ University of Maryland

1R01HL073387-01

6/30/2006

1. 5M01RR000052-420742

1. 6/30/2005

2. AIO2031

2. 7/31/2008

National Institute of Neurological Disorders and Stroke National Heart, Lung, and Blood Institute 1. National Center for Research Resources 2. NIAID

Johns Hopkins University

5M01RR000052-420803

Washington University School Of Medicine Emory University

R01HL072919-01

3/31/2008

National Center For Research Resources National Institute of Health

1. 5R01NS040825-02

1. 11/30/2004

2. 5R01NS038664-03

2. 1/31/2005

5R01NS041919-03

6/30/2005

Wayne State University

Co Poisoning In The Context Of A Reperfusion Injury Preconditioning Against A Source Of Reperfusion Oxidants Lubricin In Articulating Joints

University of Pennsylvania

5R01ES005211-14

7/31/2004

University of Chicago

5R01HL068951-02

5/31/2007

Case Western Reserve University and Rhode Island Hospital University of Florida

R01AR050180-01

8/31/2008

5P20HS011592-02

1. 1/1/2004

1. 9/15/05 2. 12/31/03

2. 9/29/2004

5P42ES005947-129004

3/31/2005

University of Pittsburgh

5R01HS010888-02

9/29/2003

Agency for Healthcare Research and Quality

Harbor-UCLA

5M01RR000425-340790

University of Michigan

5T35HL007690-23

4/30/2006

National Heart, Lung, and Blood Institute National Institute of Child Health and Human Development Agency for Healthcare Research and Quality National Institute of Neurological Disorders and Stroke National Heart, Lung, and Blood Institute National Institute of Environmental Health Sciences National Institute of Mental Health National Institute of Child Health and Human Development

6/30/2005

Health Partners Research Foundation University of Rochester

5K08HS013007-02

2/28/2007

5K23NS041952-02

8/31/2008

Dickson, Eric

University of Massachusetts

5K08HL069834-02

5/31/2006

University of Illinois at Chicago

5K08ES011302-02

3/31/2007

Children's Hospital

1K23MH063916-01

3/31/2008

Children's Hosp ital

5K08HD040848-03

6/30/2006

Hickey, Robert

2. Agency for Healthcare Research and Quality National Heart, Lung, and Blood Institute National Institute of Environmental Health Sciences

Harvard University

5K23HD001320-04

Grupp-Phelan, Jacqueline

National Institute of Neurological Disorders and Stroke 1. Agency for Healthcare Research and Quality 2. National Heart, Lung, and Blood Institute National Institute of Environmental Health Sciences National Heart, Lung, and Blood Institute National Institute of Arthritis, Musculoskeletal And Skin Diseases 1. ASHP

10/31/2003

Children's Hospital of Philadelphia

Dorevitch, Samuel

1. & 2. National Institute of Neurological Disorders and Stroke

Mohawk Innovative Technology, Inc. 1R43HL072638-01

Career Development Awards (19) Alessandrini, Evaline Predicting Vaccine Status & Ed Use In Medicaid Newborns Asplin, Brent Emergency Department Crowding: Causes And Consequences Bazarian, Jeffrey Epidemiology Of Traumatic Brain Injury Hormonal Opioids In Ischemic Preconditioning Demolition And Asthma In Chicago Public Housing Screening Services In The Pediatric Emergency Department Cox-2 And Injury In The Immature Brain

Agency for Healthcare Research and Quality National Heart, Lung and Blood Institute National Institute of Neurological Disorders and Stroke National Institute of Neurological Disorders and Stroke

5R01NS039481-04

University of Alabama At Birmingham

Minimally Invasive Blood Lactate Biosensor Core--Community Based Metals Exposure In Child Development And Hearing An Empiric Risk Stratification Rule For Heart Failure Vp 63843 In Treatment Of Enteroviral Meningitis In Adolescents&Adults Short Term Training In Health Professional Schools

National Heart, Lung, and Blood Institute National Institute of General Medical Sciences National Library of Medicine

University of Pennsylvania

1. Innovative Education For Bioterrorism 2. Public Access To Defibrillation

1. Human Factors And Usability Analysis Of Automated Dispensing Units 2. Center For Safety In Emergency Care

Awarding Institution

17

Principal Investigator

Award Title

Institution

Award Number

Project End Date

James, Laura

Novel Therapies For Acetaminophen Toxicity

University of Arkansas

5K08DK002971-03

11/30/2004

Jay, Gregory

Immunoprobes For Lubricin From Human Synovial Fluid Hospital Disaster Plans: Structure, Training & Function Informative Technology: Linking Parents And Providers A Network Of Research Units To Study Clinical Wound Care

Rhode Island Hospital

1K08AG/AR01008-01

7/31/2004

Harbor-UCLA

1F32HS013985-01

6/30/2004

Children's Hospital (Boston)

5K08HS011660-02

6/30/2005

University of California San Francisco/ Stanford University

5K23AR002137-04

3/31/2005

University of Chicago

5K23MH064572-02

6/30/2007

Johns Hopkins University

5K23RR016070-04

6/30/2005

Children's Hospital (Cincinnati)

5K08AI050006-03

6/30/2004

Brigham And Women's Hospital

5K23ES000381-03

8/31/2005

Harbor-UCLA

5K23RR016180-03

8/31/2005

University Of Michigan

1. 5K08HL003817-05

1. 1/31/2004

2. R01GM069438-01

2. 11/29/2008

Kaji, Amy Porter, Stephen Quinn, James

Rhodes, Karin Rothman, Richard Strait, Richard Wright, Robert Young, Kelly Younger, John

Non-NIH Grants (45) Angelos, Mark Barbee, Wayne Bernstein, Steve Rodney Boychuk Brown, Michael Cline, David Degutis, Linda Fein, Joel

Hargarten, Stephen

Ralph Hingson

Kelly, Kevin

Knox, Todd

Lowe, Robert

Identifying And Responding To Male Partner Violence Mentored Patient-Oriented Research Career Development Aw Cytokines Regulation Of Anaphylaxis In The Mouse Neurochemical And Genetic Markers Of Lead Toxicity Mentored Patient-Oriented Research Career Development Aw 1. Lung Injury, Perfluorocarbons, and Hemorrhagic Shock 2. Protective Effects of anti-C5a in Sepsis

Reactive Oxygen Species In Low Flow Ischemia Metabolic Engineering Strategies For Cellular Stasis Strategies To Reduce Tobacco-Related Illnesses In The Emergency Department Managing Pediatric Asthma: Emergency Department Demonstration Program Asthma Surveillance And Intervention In Hospital Emergency Departments Cardiovascular Surveillance Via A Hypertension Registry A Comparative Analysis Of Dwi Legislation In The Us And Canada 1. Screening And Secondary Prevention For Psychological Sequelae Of Pediatric Injury 2. Development Center For Traumatic Stress In Children 3. Refusal And Attrition Among Youth Enrolled In a Home Based Violence Prevention Intervention 1. Injury Research Center at the Medical College of Wisconsin 2. Analysis Of Violence Related Fatalities And Injuries In Wisconsin Peer-Based Intervention To Promote Behavior Change Among Youth In Emergency Departments Who Test Positive For Risky Drinking 1. Managing Pediatric Asthma: Emergency Department Demonstration Program 2. Allies Against Asthma: A Program To Combine Clinical And Public Health Approaches To Chronic Illness Pain and Emergency Medicine Initiative

Cooperative Agreement between USEPA/CEPPO and Wharton Risk Management Decision Process Center

Awarding Institution National Institute of Diabetes and Digestive and Kidney Diseases National Institute on Aging Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality National Institute of Arthritis And Musculoskeletal And Skin Diseases National Institute of Mental Health National Center For Research Resources National Institute of Allergy and Infectious Diseases National Institute of Environmental Health Sciences National Center For Research Resources 1. National Heart, Lung, and Blood Institute 2. National Institute of General Medical Sciences

Ohio State University

6/2004

American Heart Association

Virginia Commonwealth University

6/2004

Montefiore Medical Center

2005

Defense Advanced Research Projects Agency (DARPA) American Legacy Foundation

Kapi'olani Health Foundation

043505

2. 9/2005

Robert Wood Johnson Foundation Centers for Disease Control and Prevention Centers for Disease Control and Prevention Robert Wood Johnson Foundation 1. Emergency Medical Services for Children/Health Resources and Services Administration 2. SAMHSA

3. 1/2004

3. Firearm Injury Center (Ficap)

1. R49/CCR519614

1. 7/2006

Centers for Disease Control

2. R49/CCR519614

2. 7/2006

Boston University

043510

08/31/2004

Robert Wood Johnson Foundation

Medical College of Wisconsin

1. 043507

1. 9/30/2004

1. & 2. Robert Wood Johnson Foundation

2. 044214

2. 12/31/2004

Michigan State University Wake Forest University

1/31/2004 2004

Ts 0769

Yale University

9/29/2005 12/2004

University of Pennsylvania

Medical College of Wisconsin

37-01

Emory University and American College of Emergency Physicians Oregon Health and Science University

18

1. 2/2005

11/30/2004

The Mayday Fund, New York, New York

8/31/2003

Environmental Protection Agency (EPA)

Principal Investigator Maio, Ronald

Macias, Charles Meldon, Steve

Mello, Michael

Rothman, Richard Schull, Michael

Shah, Manish Silvotti, Marco

Award Title

Institution

Award Number

1. Non-hospitalized traumatic brain injury: University of Michigan Michigan incidence, impact, and cost 2. Great Lakes regional node for pediatric EMS research

1. R49/CCR523223-01

1. 9/30/2006

2. U03MC00003-01

2. 9/30/2005

3. Methods to Determine the Value of EMS

3. 98-05117

3. 11/30/2005

Managing Pediatric Asthma: Baylor College of Medicine Emergency Department Demonstration Program An Ed-Based Falls Prevention Screening Case Western Reserve University And Referral Program

043506

9/30/2004

1. Phone Intervention of ETOH Brown University use in ED MVC patients 2. Injury Free Coalition for Kids in Providence at Hasbro Children’s Hospital Rapid HIV Testing in the ED Johns Hopkins University 1. Causes And Relationships Between University of Toronto Overcrowding And Waiting In Different Emergency Departments: The Crowded Study.

2. Pre-Hospital And Emergency Services In Canada.

Prehospital Screening To Prevent Injuries University of Rochester And Illnesses 1. "Is Etomidate Being Underdosed For Queen's University at Kingston Emergency Rapid Sequence Intubation";

1. R49/CCR1232280-01

1. 9/2006

2. 047099

2. 11/2006

7/2004

12/31/2005 2006

2005 1. 2004

2. "Canadian Acetaminophen Overdose Study";

Stern, Susan

Stephen Teach Terndrup, Thomas

Wright, David

Project End Date

2. 2004

3. "Hepatotoxicity Following Therapeutic Doses Of Acetaminophen In Recovering Alcoholics" Optimizing Resuscitation For The Casualty University of Michigan With Combined Hemorrhagic Shock And Traumatic Brain Injury Managing Pediatric Asthma: Children's Research Institute 043508 Emergency Department Demonstration Program 1. Rural Access To Emergency Devices 1. State Alabama Department 2. Integrated Healthcare Leadership of Public Health Training In Response To Weapons 2. Noble Training Center, Anniston, Alabama Of Mass Destruction Neurorehabilitation With Progesterone And Pregnenolone

Emory University

Awarding Institution 1. Centers For Disease Control (CDC) 2. Department of Health and Human Services, Maternal Child Health Bureau, Emergency Medical Services for Children 3. NHTS/National Assoc. of State EMS Directors Robert Wood Johnson Foundation American Geriatrics Society and The John A. Hartfod Foundation 1. Centers for Disease Control and Prevention 2. Robert Wood Johnson Foundation Maryland Dept. of Health Canadian Institutes of Health Research

Hartford Foundation/American Geriatrics Society 1. Ministry Of Health Of Ontario (Emergency Health Services Branch) 2. Physicians' Services Inc Foundation

6.5 Years

Department of Defense Office of Naval Research

9/30/2004

Robert Wood Johnson Foundation 1. Health Resources and Services 2. Administration Department of Homeland Security National Center for Medical Rehabilitation Research

12/2006

2003

HHS Completes E-Grants Site The SAEM Newsletter is mailed every other month to approximately 6000 SAEM members. Advertising is limited to fellowship and academic faculty positions. The deadline for the May/June issue is April 1, 2004. All ads are posted on the SAEM website at no additional charge.

Advertising Rates: Classified ad (100 words or less) Contact in ad is SAEM member Contact in ad non-SAEM member Quarter page ad (camera ready) 3.5” wide x 4.75” high

Organizations interested in federal grants can now visit one web site to find application materials and other related information. The Health and Human Services Department announced the completion of www.grants.gov, a site providing "one-stop" grants shopping. The site includes information about more than 800 grant opportunities at 26 agencies. Potential grant applicants can search Grants.gov to view listings of available funding. Once they have selected a grants program, they can download applications and submit the forms online. Not all agencies have posted application materials yet, but forms are available from HHS and the Commerce, Education, Energy and Justice departments.

$100 $125 $300

To place an advertisement, email the ad, along with contact person for future correspondence, telephone and fax numbers, billing address, ad size and Newsletter issues in which the ad is to appear to: Carrie Barber at carrie@saem.org

19

“Tragedy of the Commons”

(Continued)

tragedy of the commons would be to institute negative social or financial incentives to reduce inappropriate use of EMS or emergency department resources. Such an approach raises difficult ethical issues regarding the rights of individuals to access medical care freely versus the rights of the population as a whole to have high-quality emergency care available when needed.

There are a number of related and very difficult research questions which would need to be addressed regarding the definition and detection of inappropriate use and the reliability and validity of any measures used to define inappropriate utilization.

Examples of this approach includes the use of small financial co-payments which could be refunded if a patient requires admission to the hospital from the emergency department.

Interestingly, emergency physicians often react emotionally to such solutions, and often believe that this reaction is in the best interest of their patients. In truth, however, some approach to manage the commons that is emergency care will be required if we are to preserve the quality of emergency care for all patients. In other words, we must take an active role to managing the commons if we are to preserve it, rather than reacting negatively and emotionally towards any attempt to manage it.

Focusing on the development of research capability within a department, active management of each limited resource is again the key. This may include active management of a mentor’s time, active management of protected time, and the active management of other resources (e.g., funds for tuition, equipment, and support personnel). Such an approach requires “mutually agreed upon” sacrifice by others in the department, and in the institution, so that adequate resources can be identified to allow an intensive and sustained investment in the initial research career of young investigators. Without such an investment, however, we will be consistently setting up our young investigators to fail, and then finding external excuses to explain their failure.

In summary, in a setting of limited resources, a blind devotion to equal allocation of resources severely limits the research potential of a department.

Since an adequate investment in a promising young investigator must occur early in their career, be sustained,

and be intensive, this can only occur with a mutually agreed upon sacrifice by others in the department. Thus, support of colleagues is critical and, in many departments, such support will not occur without a fundamental change in the culture of the department.

Closing Thoughts While I take personal pride in the tradition of equal and unfettered access to medical care that characterizes emergency medicine, we must learn the lessons taught by the Tragedy of the Commons if we are to preserve the quality of this care for those who need it.

This will require active management of limited resources, rather than a singleminded devotion to equality and unfettered access. Likewise, if we are to realistically and meaningfully support the development of research capability within emergency medicine, we must be willing to disproportionately shift resources, whether they are a mentor’s time or protected academic time, to our promising young investigators. This will require a sacrifice by many so that a few may push the limits of our academic specialty.

Emergency Medicine 1999;6:286291.

9. NIH National Research Service Award Institutional Research Training Grants.

Accessed at http://grants1.nih.gov/grants/guide/ pa-files/PA-00-103.html on February 1, 2004.

10. Holden C. “Tragedy of the Commons” Author Dies. Science 2003;302:32.

Table. Key Elements of Research Training.

• Access to Formal Coursework • Mentor • Protected time • Facilities, equipment, and supplies • Supportive environment (mentor, chair, colleagues) Figure. Departmental Development.

Research

[Editor’s note: The biologist who wrote the landmark 1968 article on the Tragedy of the Commons recently passed away.10] References 1. Hardin G. The Tragedy of the Commons.

Science 1968;162:1243-1248.

2. Hardin G. Extensions of “The Tragedy of the Commons.” Science 1998;280:682-683.

3. Kennedy D. Sustainability and the Commons [Editorial].

Science 2003;302:1861.

4. Dietz T, Ostrom E, Stern PC. The Struggle to Govern the Commons.

Science 2003;302:1907-1912.

5. Adams WM, Brockington D, Dyson J, Vira B. Managing Tragedies: Understanding Conflict over Common Pool Resources. Science 2003;302:1915-1916.

6. Mascie-Taylor CGN, Karim E. The Burden of Chronic Disease.

Science 2003;302:1921-1922.

7. 42 CFR §489.24 8. Blanda M, Gerson LW, Dunn K. Emergency Medicine Resident Research Requirements and Director Characteristics. Academic 20

Newsletter Submissions Welcomed SAEM invites submissions to the Newsletter pertaining to academic emergency medicine in the following areas: 1) clinical practice; 2) education of EM residents, off-service residents, medical students, and fellows; 3) faculty development; 4) politics and economics as they pertain to the academic environment; 5) general announcements and notices; and 6) other pertinent topics. Materials should be submitted by e-mail to saem@saem.org. Be sure to include the names and affiliations of authors and a means of contact. All submissions are subject to review and editing. Queries can be sent to the SAEM office or directly to the Editor at david.cone@yale.edu.

FACULTY POSITIONS CONNECTICUT: University of Connecticut/Hartford Hospital:Section Head--Pre Hospital Programs. Senior administrative faculty position to oversee all aspects of Ground and Air EMS. Multi Hospital program with 100,000+ patient visits, 36 EM residents, fellowships, two helicopters. Reply to Robert D. Powers MD MPH, Professor and Chief of EM--email:Rpowers@Harthosp.org MICHIGAN: Michigan State University – Kalamazoo Center for Medical Studies The Department of Emergency Medicine is seeking a Director of Pediatric Emergency Medicine to serve as academic faculty for our emergency medicine residency program. Candidates must be BC/BP in emergency medicine, as well as BC/BP in pediatrics or pediatric emergency medicine. This exciting opportunity involves outstanding compensation and benefits, protected academic time, and a delightful university community in which to live and work. Please contact: David Overton MD, MBA, Michigan State University - Kalamazoo Center for Medical Studies, 1000 Oakland Drive, Kalamazoo, MI 49008

The Department of Emergency Medicine of Texas Tech University School of Medicine is seeking an experienced Emergency Medicine residency trained physician to assume leadership of it’s residency program. The program is over twenty years old, fully accredited and has twenty-four residents at present. The candidate would join 15 EM physicians in the Department. Our mission is to prepare residents to be able to practice in any ED in the country. The Department is located in El Paso, Texas and will soon be incorporated into the new 4 year medical school just approved by the state legislature. Our new offices are under construction on campus and a new $36 million research building is in late design phase for the campus. Our main ED is at Thomason Hospital with a patient volume of 60,000 visits last year. It is a Level I Trauma Center and is opening a new $25 million wing, including the ED Observation Unit next year. For more information on the residency visit http://www.elp.ttuhsc.edu/em

NEW JERSEY: UMDNJ (Newark) – Come in on the ground floor at a major medical school and university hospital. We're planning to start an EM Residency and have faculty opportunities for Emergency Physicians at ALL LEVELS, including Residency Director, EMS Director and Director of Clinical Operations. The ED has an annual volume of 72,000, including 2,700 level I trauma patients.

Competitive compensation and benefits package including on-site fitness andchild care centers. For information please contact Ronald Low, MD, MS, at 973972-7882. UMDNJ-University Hospital is an AA/EOE, M/F/D/V. Visit us on the web at www.TheUniversityHospital.com.

OHIO: The Ohio State University - Assistant/Associate or Full Professor.

Established residency training program. Level 1 Trauma center. Nationally recognized research program. Clinical opportunities at OSU Medical Center and affiliated hospitals. Send curriculum vitae to: Douglas A. Rund, MD, Professor and Chairman, Department of Emergency Medicine, The Ohio State University, 146 Means Hall, 1654 Upham Drive, Columbus, OH 43210, email Dailey.1@osu.edu, or call (614) 293-8176. Affirmative Action/Equal Opportunity Employer.

Please send a letter, or email, expressing interest to: Matthew J. Walsh, MD, Associate Professor and Chair, Dept. of EM, 6090 Surety Dr. #412, El Paso, Texas 79905.

Email mwalsh1@elp.rr.com or phone 915-771-6482.

Texas Tech University is an Equal Opportunity Employer.

Women and minorities are encouraged to apply.

OREGON: Fellowship: Combined EMS/ Emergency Preparedness Education fellowship available as of June 30, 2004. OHSU has an Emergency Medicine residency in a level I trauma center and tertiary pediatric hospital, and is the home to a tri-state regional poison control center, a multi-county base for EMS operations and training, an original site for MMRS disaster preparedness, and faculty with expertise in infectious, chemical, and nuclear injury. We are expanding our mission to be a center of expertise in bioterrorism preparedness and training, and seek an EM trained individual for a 1 to 2-year fellowship. Opportunities also exist to combine the fellowship experience with MPH degree or diploma programs in clinical research, public health, health policy, epidemiology, and informatics. Please contact Zane Horowitz, horowiza@ohsu.edu or Mohamud Daya, dayam@ohsu.edu.

OREGON: The Oregon Health & Science University, Department of Emergency Medicine is conducting an ongoing recruitment campaign for talented faculty members. Entry-level clinical faculty members at the instructor and assistant professor level. Preference given to those with fellowship training (especially in pediatric emergency medicine) or equivalent experience. Knowledge of emergency medicine as a faculty discipline is expected. Please submit a letter of interest, CV, and the names and phone numbers of three references to: Jerris Hedges, MD, MS, Professor & Chair, OHSU Department of Emergency Medicine, 3181 SW Sam Jackson Park Road, CDW -EM, Portland, OR 972393098.

ASSOCIATE RESIDENCY DIRECTOR We are recruiting an Associate Residency Director for an established EM program. The University of Rochester is a Level 1 Trauma Center with 90,000 visits per year. We currently have 30 residents and fellowships in Pediatrics, Sports Medicine and EMS.

PENNSYLVANIA: Penn State University College of Medicine & Hershey Medical Center – Department of Emergency Medicine is seeking to add experienced academic emergency physicians to our internationally known faculty. We are seeking faculty to supplement our research and educational missions and participate with our newly approved PENN STATE EMERGENCY MEDICINE RESIDENCY. Physicians must be board certified with some academic experience.

Faculty rank will be commensurate with experience. Confidential inquiry to Kym Salness, M.D. (Chair) or Christopher J. DeFlitch, M.D. (Vice-Chair), Department of Emergency Medicine, P.O. Box 850 (H043), Hershey, PA 17033, Phone (717) 531-8955 or email cdeflitch@psu.edu or www.pennstateemergencymedicine.com. AAEOE. Women and minorities are encouraged to apply.

Applicants with enthusiasm for teaching, excellent organizational skills and an interest in high fidelity simulation should apply. Applicants must be EM resident trained. Protected time for administrative duties provided.

University of Rochester is an equal opportunity employer.

Contact: Sandra Schneider, M.D., Chair Department of Emergency Medicine, University of Rochester 601 Elmwood Avenue, Box 655 Rochester, NY 14642.

Phone (585) 275-9490; fax (585) 506-0052; E-mail: Sandra_Schneider@urmc.rochester.edu

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Louisiana State University Health Sciences Center Shreveport, Louisiana

Medical Director of Clinical Services The Department of Emergency Medicine at Louisiana State University Health Sciences Center is seeking a full-time faculty to serve as Medical Director of Clinical Services for our academic department that will begin a residency training program July 2004. LSUHSC is the tertiary referral center for entire region with annual volume of 60,000 and serves as the only Level I Trauma Center in the area.

Interested individuals should be EM residency trained and boarded with a strong background in process improvement and excellent people skills. This is a great opportunity for involvement in both resident education and medical direction from the very beginning. LSUHSC is an Equal Opportunity/Affirmative Action employer.

Applicants should contact: Thomas C. Arnold, M.D. Chairman, Department of Emergency Medicine LSUHSC-Shreveport 1501 Kings Highway P.O. Box 33932 Shreveport, LA 71130-3932 (318) 675-6885 or fax (318) 675-6878

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Newark Beth Israel Medical Center An Affiliate of the St. Barnabas Health Care System

Department of Emergency Medicine

Director of Academic Affairs We are searching for an emergency medicine physician experienced in research, academics, grant writing, and residency administration to assume a key leadership role in our department. We are looking for an enthusiastic, energetic individual who is 5-10+ years post-EM residency graduation and desires an opportunity to lead a team of talented, dedicated faculty and be part of an Emergency Department committed to scholarship, clinical excellence, community service, and humanistic values. An MS or MPH and/or expertise in medical toxicology or ultrasound would be a very desirable plus. Academic appointment at the Mount Sinai School of Medicine. Applicant must be able to qualify at the Associate Professor or Professor level. This position carries a very competitive compensation package and ample protected time commensurate with experience and seniority. Please contact or forward your CV/letter of interest to Marc Borenstein, MD, Chair, Department of EM, Newark Beth Israel Medical Center, 201 Lyons Ave, Newark, NJ 07112, phone - (973) 926-7562, e-mail - mborenstein@sbhcs.com.

Take Pride. Take Ownership. Deliver Excellence.

Patients 1st.

Faculty Positions In conjunction with starting Iowa’s first ACGME accredited Emergency Medicine training program and academic Department of Emergency Medicine, the University of Iowa is actively seeking clinical and tenure track faculty members to fill newly created core faculty positions.

Competitive applicants will have completed an ACGME accredited emergency medicine residency-training or pediatric emergency medicine program and be actively participating in research or residency training.

Qualified individuals will receive significant release time to develop their academic interests. Clinical duties will be performed at the University of Iowa Health Care’s Emergency Treatment Center; the regions only level one trauma center. Successful applicants interested in either basic science or clinical research careers will be aligned with an appropriate NIH funded mentor and receive considerable start up funds to jump-start their academic career. Iowa City is a beautiful outdoor and family oriented community located along the banks of the Iowa River just 200 miles west of Chicago and was recently named the number 6 city to live in by Men’s Journal. Applicants should send a CV to Eric Dickson, M.D., Director, Program in Emergency Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive – Rm. 1193 RCP, Iowa City, IA, 52242-1009. The University of Iowa is an Equal Opportunity and Affirmative Action Employer. Women and minorities are strongly encouraged to apply.

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Emergency Medicine Research Fellowship

The Mount Sinai School of Medicine Department of Emergency Medicine is pleased to offer a two-year research fellowship position to begin in July 2004.

Research project will be tailored to the interest of the research fellow and his/her long-term career plans.

Opportunity to attend academic classes leading to a Masters Degree in Public Health or Clinical Research.

Fellows will be mentored and supported in the preparation of research grant applications appropriate to their experience and interests.

Limited clinical responsibilities at one of our five affiliated hospitals Participation in training medical students and EM residents Academic appointment in the Department of Emergency Medicine The successful applicant will have completed residency training in Emergency Medicine at an accredited program and will have demonstrated interest and/or experience in biomedical, clinical or health services research. Interested individuals should send a Curriculum Vita, names and contact information of three references, and a letter describing their qualifications and interests. An interview will be required. Women and minorities are encouraged to apply.

To apply or to obtain more information contact the Research Fellowship Director: Lynne D. Richardson, MD at: lynne.richardson@mssm.edu.

The Mount Sinai School of Medicine is an equal opportunity employer.

The Department of Emergency Emergency Medicine the Boston University School of MedicineatFaculty Position Medicine (BUSM)) seeks academic faculty members. Positions are available Department of Emergency Medicine at the Boston University School of atThe Boston Medical Center (BMC) which is a Level 1 Trauma Center with Medicine (BUSM)) seeks academic faculty members. Positions are available 124,000 visits annually.

The(BMC) Department serves as an independent at Boston Medical Center which of is aEM Level 1 Trauma Center with 124,000 visits annually.

TheBUSM Department of EM serves as an independent academic department within and BMC. academic department within BUSM and BMC.

Thedepartment departmenthas hasaanationally nationallyrecognized, recognized,well-established well-establishedresidency residency The programwith withacademic academicfaculty facultyappointments appointmentsthrough throughBUSM. BUSM.BMC BMCisisthe the program medical control and academic base for Boston EMS. In addition, we have an medical control and academic base for Boston Inhealth, addition, we have an active research section with particular focus onEMS. public administration, EMS and cardiovascular emergencies.

Candidates must be ABEM board active research section with particular focus on public health, administration, certified or eligible and must demonstrate a commitment to the training of EMS and cardiovascular emergencies.

Candidates must be ABEM board emergency medicine residents. Competitive salary with an excellent benefits certified package.or eligible and must demonstrate a commitment to the training of emergency medicine residents. Competitive salary with an excellent benefits Further information contact: Jonathan Olshaker MD, Professor and Chair, package.

Department of Emergency Medicine, Boston Medical Center, 1 BMC Place, Boston MA 02118-2393. Tel: 617-414-5481; Fax: 617-414-7759; E-mail: olshaker@bu.edu.

EqualJonathan Opportunity/Affirmative Action Employer.

Further informationAn contact: Olshaker MD, Professor and Chair, Department of Emergency Medicine, Boston Medical Center, 1 BMC Place, Boston MA 02118-2393. Tel: 617-414-5481; Fax: 617-414-7759; E-mail: olshaker@bu.edu. An Equal Opportunity/Affirmative Action Employer.

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Y O U R

P L A C E

I S

AT

WWW.MMC.ORG

Director of Pediatric Emergency Medicine The Department of Emergency Medicine at Maine Medical Center is seeking a full-time Director of Pediatric Emergency Medicine to join an accomplished and growing academic faculty at our full-service tertiary care medical center. In addition to the commitment to excellent patient care, education and scholarly production shared by our entire group, this individual will have the privilege of building a “Center for Excellence in Pediatric Emergency Care” – a program that has been endorsed and funded by hospital leadership. Candidates must be boardcertified or prepared in Emergency Medicine with additional training in either Pediatrics or Pediatric Emergency Medicine.

Maine Medical Center is a 606-bed tertiary care and teaching hospital with a multi-state referral base located in Portland, Maine. Our institution is home to an outstanding emergency medicine residency program as well as a broad spectrum of independent residencies and fellowships.

Emergency Medicine faculty hold academic positions at the University of Vermont School of Medicine.

Portland offers one of the country’s most picturesque coastlines on the eastern seaboard with countless recreational activities and a wealth of cultural attractions. This is truly a wonderful place to live and practice emergency medicine.

Interested candidates should send a cover letter and curriculum vitae to: Michael A. Gibbs, MD, Chief, Department of Emergency Medicine, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102; Phone: 207-842-7010; Fax: 207-842-7025. EOE. Participating member of the Diversity Hiring Coalition of Maine.

The MaineHealth Family

Pediatric EM Faculty Position

EMERGENCY MEDICINE RESIDENCY DIRECTOR

Penn State's Milton S. Hershey Medical Center, Department of Emergency Medicine and Penn State Children's Hospital in Hershey, PA is seeking a Pediatric Emergency Medicine academic faculty to join the Emergency Medicine faculty. The applicant should be trained in pediatric emergency medicine and would have the opportunity for dual appointments in the Department of Emergency Medicine, and Pediatrics. As the only Children's Hospital between Pittsburgh and Philadelphia, with a Level 1 Pediatric trauma center, we train high quality residents in the Penn State Emergency Medicine and Pediatric residencies, as well as students from the Penn State College of Medicine.

With a growing census of 46,000 per year, 23% of which are complex and routine pediatric patients, we are expanding our faculty and space dedicated to Pediatric Emergency Medicine. The Department of Emergency Medicine also boasts of a strong ultrasound, ground EMS, areomedical helicopter and observational medicine programs. There is an outstanding and expanding 15-person, faculty group. This opportunity combines comprehensive university health care, a medical school, an attractive small community lifestyle, excellent schools, and fabulous recreational and cultural opportunities in south central Pennsylvania. There are ample opportunities for clinical research, if interested. Contact Kym A. Salness, M.D., FACEP, Chair or Christopher J. DeFlitch, M.D., Vice-Chair, Department of Emergency Medicine (H043), PO Box 850, Hershey, PA 17033 - phone (717) 5318955 or e-mail at cdeflitch@psu.edu. The Penn State University Milton S. Hershey Medical Center is an affirmative action/equal opportunity employer. Women and minorities are encouraged to apply.

University Physician Associates, the faculty practice plan for the University of Missouri-Kansas City School of Medicine, is seeking a new emergency medicine residency director. The program, clinically based at Truman Medical Center, was established in 1973 and currently admits 9 residents per year into its EM-1,2,3 curriculum.

The ED has an annual patient census of 56,000, and is currently undergoing a $15 million expansion which will nearly double its capacity. Expansion of faculty and resident complements is in the planning stages.

The School of Medicine recently purchased a medical simulator for the department with the expectation that we will create a center of excellence in undergraduate and graduate medical simulation. The successful candidate will have a minimum of three years experience as an assistant or associate program director, and will have a demonstrated track record of scholarly achievement in the area of education. Salary, benefits, and academic rank will be commensurate with experience and achievement. Send CV and letter of interest to: Robert A. Schwab, MD, Professor and Chair, Department of Emergency Medicine, 2301 Holmes Street, Kansas City, Missouri 64108. Robert.Schwab@tmcmed.org

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2004 AACEM Annual Meeting and Workshop Saturday, May 15, 2004

Annual AACEM Educational Session (attendance limited to AACEM members and an AACEM member guest) 7:00 am Continental Breakfast 7:30 am

Review of Schedule; Introductions

8:00 am

Keynote Speaker - Michael O'Connor Michael O'Connor is the Chair of the first Department of Emergency Medicine in Canada and is the Chair of the Emergency Medicine Program Committee for the Royal College of Physicians and Surgeons of Canada (a body that fulfills RRC and ABEM roles for Emergency Medicine). He will provide an overview of the development of academic emergency medicine in Canada. He will address the challenges for the future and related strategies for the development of academic emergency medicine in Canada.

9:15 am

Moderated Topics (speakers) Faculty Incentives and Rewards - Frank Pettyjohn Faculty Evaluation - Waste of Time or Motivational Tool? - Sandra Schneider Difficult Faculty Member - Arthur Kellermann Strategies for Aging Faculty Members - Norman Christopher Care and Feeding of the Dean - Barry Brenner Alternative/Innovative Programs for Support of the Academic Department - Robert Shesser Preserving the Academic Mission in Difficult Fiscal Times - Brooks Bock Establishing Endowments - Why and How - Francis Counselman

11:30 am

Brief Late-Breaking Topic Presentation

Annual AACEM Business Meeting (AACEM members only) 12:00 pm Annual Business Meeting - Lunch

AACEM New and Future Chairs of Emergency Medicine Workshop AACEM is pleased to offer the New and Future Chairs Workshop on May 15, 2004 in Orlando. This program has recruited Emergency Medicine exemplar leaders who will discuss critical issues that can contribute to becoming a successful academic chair and leader in Emergency Medicine. An informal gathering will immediately follow the last session.

1:30-2:30 pm

Leadership Principles and Skills: how to be a successful chair and leader and avoid failure, John Marx, MD, Carolinas Medical Center and Glenn Hamilton, MD, Wright State University This leadership session is focused on models of chair successes and ways to avoid failures. The philosophy of departmental leadership (e.g., "lead by example", "lead by consensus") and the role of other departmental leaders such as residency program director, vice-chair, operations chief will be discussed. Group dynamics and personality types; institutional hierarchy; serving as a "change leader" and overcoming institutional inertia; and conflict resolution techniques are just some of the content areas to be explored.

2:30-3:30 pm

Advancing Emergency Medicine in Medical Schools/Hospitals/Practice Plans: Insights/Advice, Lewis Goldfrank, MD, Bellevue Hospital Center and Brooks Bock, MD, Wayne State University In this session, negotiating principles, development of allies, neutralizing enemies, use of institutional resources, and developing an academic base will be discussed. The session presenters are experienced Emergency Medicine leaders who will share their experiences and lessons.

3:30-4:30 pm

Business and Finance: how to assure a successful bottom line, Jerris Hedges, MD, MS, Oregon Health and Science University and Nicholas Benson, MD, MBA, East Carolina University In this session, mission based administration, faculty incentive/bonus plans, and budget negotiations will be discussed. This session will build on the experience of these physician leaders in their respective departments and medical schools

All SAEM members and others are invited to attend this Workshop. The registration fee is $100 (refundable to AACEM members after verification of attendance). To register, send an email to saem@saem.org stating you would like to attend the Workshop and indicate your method of payment. Checks should be made payable to AACEM and mailed to 901 N. Washington Ave., Lansing, MI 48906.

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The Business Aspects of Health System Management: The Emergency Physicians’ Role in Health System Leadership May 15, 2004 (day before SAEM Annual Meeting) Health care continues to change and emergency department resources are being stretched to their limits, if not beyond.

Academic physicians are frequently being asked to participate in the daily management and operations of various clinical activities, yet they have little management training. The goal of this physician developed and tested curriculum is to introduce fundamental business and managerial tools to the academic emergency physician. This session has been developed by SAEM as a special pre-day offering at the 2004 Annual Meeting in Orlando.

This program is a condensed version of the University of Michigan management training program which has been delivered to over 500 physicians within various Health Systems across the USA. The course condenses the first-year MBA curriculum into a tightly packed one-day curriculum as applied to Integrated Health Systems. While the roots of the program are derived from an academic perspective, the design and delivery are relevant to both academic and community settings. The goal of this curriculum is to provide the clinician and administrator (Chair and Clinical Director) with the necessary tools to change their practice to optimize the delivery of health care tomorrow. This course delivers content on the basic economics of health care, cost accounting, operations management, finance, reimbursement and risk management, and physician leadership. Real emergency department financial and operational metrics data and examples will be presented throughout the course. Upon completion of this course, attendees will be armed with tools to optimize health care delivery and enhance their ability to conduct research and education in ED operations management. The target audience is mid-level to senior physicians (clinical and administrative) and administrative personnel. The registration fee is $200 and interested individuals can register via the online Annal Meeting registration form at www.saem.org.

8:30 – 9:10 David Butz

Economics, cost accounting, and risk management: This session begins with an introduction to the hospital’s cost accounting system and the underlying economics of health care costs. Concepts include activity-based costing, direct and indirect costs, fixed and variable cost, average and marginal cost, and opportunity cost. We will also break out payment and profit margins under traditional fee-for-service insurance, DRG-based payments, and “capitated” reimbursement -while showing the risks inherent in each arrangement, the incentives created (good and bad), and some repercussions for physicians.

10:30 – 11:30 Applied operations management: This session includes three brief segments. First, it elaborates on some elements of David Butz activity-based costing that were not covered during the first lecture. Second, it discusses how physicians could creatively make more intensive use of their fixed capacity. Third, it illustrates how physicians might make use of financial data as a research tool.

11:30 – 12:30 Integrating business principles into the delivery of care: Open analysis and different thinking can improve the quality Paul Taheri of care while markedly reducing costs. Physicians need information that provides a healthy tension between resource use and quality of care.

1:30 – 2:30 David Butz

Health system strategies demystified: In this module we look at investments made by health systems and the rationale utilized to justify these investments.

2:50 – 3:45 Paul Taheri

Clinical examples of applied business principles: This module provides a walk-through of some real life examples of programs that have been developed and implemented within a health system. The benefits, risks, and pitfalls are high lighted.

3:45 – 4:45 Paul Taheri

Physician leadership: This session addresses how physicians can create learning organizations that enable effective, efficient delivery of quality healthcare, and identifies the role in developing leadership in the enterprise.

4:45 – 5:15

Roundtable discussion: This forum provides an opportunity for the course participants to ask detailed questions of the faculty.

Course Faculty Paul A. Taheri, MD, MBA: Dr. Taheri graduated medical school from New York University in 1988 and completed a general surgical residency at Tulane University in 1994. He completed his MBA from the University of Michigan Business School (UMBS) in 1999. He is currently the Division Chief of Trauma Burn Surgery and the Associate Dean for Academic Business Development.

Together with David Butz, he is the founder and Co-director of the Center for Health Care Economics, a University of Michigan Business School and Medical School joint initiative.

David A. Butz, PhD: Dr. Butz received his PhD in Economics in 1986 from Northwestern University. He served on the faculty of the Economics Department at the University of California at Los Angeles from 1987-1994 and on the University of Michigan faculty from 1994 to present. At the Business School, he has taught core Applied Microeconomics and Operations Management to 1st-year MBAs, and a 2nd-year MBA elective on Distribution and Supply Chain Management. He has won many teaching awards, and in 1995 the UMBS MBA students voted him Professor of the Year. Business Week’s Guide to the Best Business Schools has identified him as one of Michigan’s best teachers. He was also singled out for teaching excellence by students at UCLA and Northwestern. He has participated in executive education and distance learning pilot projects that have utilized videoconferencing and Internet delivery. He now serves on the faculty of the Department of Surgery at the University of Michigan Medical School, where his research and teaching focus on health care economics and outcomes research. Together with Paul Taheri, he is the founder and co-director of the Center for Health Care Economics. His other research expertise lies in industrial organization, law & economics, antitrust, and supply chain contracting, where he has published numerous peer-reviewed articles on those topics.

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S A E M

NEWSLETTER

Society for Academic Emergency Medicine 901 N. Washington Avenue Lansing, MI 48906-5137

Presorted Standard U.S. Postage PAID Lansing, MI Permit No. 485

Newsletter of the Society for Academic Emergency Medicine Board of Directors Donald Yealy, MD President Carey Chisholm, MD President-Elect James Adams, MD Secretary-Treasurer Roger Lewis, MD, PhD Past President Valerie DeMaio, MD Leon Haley, Jr, MD, MHSA Glenn Hamilton, MD Stephen Hargarten, MD, MPH Katherine Heilpern, MD James Hoekstra, MD Susan Stern, MD

Editor David Cone, MD David.Cone@yale.edu Executive Director/Managing Editor Mary Ann Schropp mschropp@saem.org Advertising Coordinator Carrie Barber Carrie@saem.org

“to improve patient care by advancing research and education in emergency medicine”

The SAEM newsletter is published bimonthly by the Society for Academic Emergency Medicine. The opinions expressed in this publication are those of the authors and do not necessarily reflect those of SAEM.

Advertising Positions Available at Annual Meeting SAEM is again offering an opportunity to advertise in the on-site program. The Annual Meeting will be held May 16-19 in Orlando and will attract approximately 1,800 academic emergency physicians.

A limited amount of space is being set aside for the position available section and only academic positions available will be accepted. The deadline for receipt of ads at the SAEM office is April 23. Please email ads to carrie@saem.org.

The following ad requirements and prices are available for the on-site program: Classified line ads (100 words maximum): $100 (contact SAEM member) or $125 (non-SAEM member) Quarter page ads: 31⁄2” wide x 43⁄4” deep Half page ads: 71⁄2” wide x 43⁄4” deep or 31⁄2” wide x 93⁄4” deep Full page ads: 71⁄2” wide x 93⁄4” deep

$300 $350 $450

A typesetting fee ($25-$50) will be charged if the quarter, half, or full page ads are not camera-ready.

Call for Abstracts 14th Annual Midwest Regional SAEM Meeting

September 9-10, 2004 The Wyndham Milwaukee Center Hotel Milwaukee, Wisconsin The Program Committee is now accepting abstracts for review for oral and interactive poster presentations.

The meeting will take place Thursday, September 9, 2004, 6:30-8:30 pm, and Friday, September 10, 2004, 8:00 am-4:00 pm at the Wyndham Milwaukee Center Hotel, 139 East Kilbourn Avenue, Milwaukee, WI 53202.

The deadline for abstract submission is Friday, July 9, 2004, by 3:00 pm EDT. Only electronic submissions via the SAEM online abstract submission form at www.saem.org will be accepted. Acceptance notifications will be sent in late July.

Registration forms are available from Dawn Kawa, Department of Emergency Medicine, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, FEH Room 1870, Milwaukee, WI 53226 or dkawa@mcw.edu.

Registration Fees: Faculty--$75; Other health care professionals--$40; Fellows/residents/students--No Charge. Late fee after Wednesday, September 1, 2004: add $10. For questions or additional information, call 414-805-6452.

Keep Your Membership Mailings Coming!

Be sure to keep the SAEM office informed of changes in your address, phone or fax numbers, and especially your e-mail address. SAEM sends infrequent e-mails to members, but only regarding SAEM issues or activities. SAEM does not sell or release its mailing list or e-mail addresses to outside organizations. Send updated information to carrie@saem.org