SAEM Pulse March-April 2021 by Society for Academic Emergency Medicine

MARCH-APRIL 2021 | VOLUME XXXVI NUMBER 2

www.saem.org

SPOTLIGHT CHAMPIONING OLDER ADULTS IN THE EMERGENCY DEPARTMENT An Interview with

Christopher R. Carpenter, MD, MSc

ADVICE FOR CONTRACT NEGOTIATIONS FROM A HEALTH CARE ADMINISTRATOR TURNED PHYSICIAN - PART 2 page 50

Leading the advancement of emergency care through education and research, advocacy, and professional development in academic emergency medicine.

SAEM STAFF Chief Executive Officer Megan N. Schagrin, MBA, CAE, CFRE Ext. 212, mschagrin@saem.org Director, Finance & Operations Doug Ray, MSA Ext. 208, dray@saem.org Manager, Accounting Hugo Paz Ext. 216, hpaz@saem.org Manager, IT Dan San Buenaventura Ext. 225, DSanBuenaventura@saem.org Specialist, IT Support Simeon Dyankov Ext. 217, sdyankov@saem.org Director, Governance Kat Nagasawa, MBA Ext. 206, knagasawa@saem.org Coordinator, Governance Michelle Aguirre, MPA Ext. 205, maguirre@saem.org Director, Publications and Communications Stacey Roseen Ext. 207, sroseen@saem.org Manager, Journals and Communications Tami Craig Ext. 219, tcraig@saem.org Manager, Digital Communications Snizhana Kurylyuk Ext. 201, skurylyuk@saem.org Director, Foundation and Business Development Melissa McMillian, CNP Ext. 203, mmcmillian@saem.org Senior Manager, Development for the SAEM Foundation Julie Wolfe Ext. 230, jwolfe@saem.org

HIGHLIGHTS Manager, Business Development John Landry, MBA Ext. 204, jlandry@saem.org Director, Membership & Meetings Holly Byrd-Duncan, MBA Ext. 210, hbyrdduncan@saem.org Sr. Manager, Membership George Greaves Ext. 211, ggreaves@saem.org Education Manager Andrea Ray Ext. 214, aray@saem.org Specialist, Membership Recruitment Berenice Lagrimas Ext. 222, blagrimas@saem.org Membership & Meetings Coordinator Monica Bell, CMP Ext. 202, mbell@saem.org Meeting Assistant Maja Keska Ext. 218, mkeska@saem.org AEM Editor in Chief Jeffrey Kline, MD AEMEditor@saem.org AEM E&T Editor in Chief Susan Promes, MD AEMETeditor@saem.org AEM/AEM E&T Manager Tami Craig Ext. 219, tcraig@saem.org AEM/AEM E&T Peer Review Coordinator Taylor Bowen tbowen@saem.org Associate Editor, Pulse RAMS Section Aaron R. Kuzel, DO, MBA aaron.kuzel@louisville.edu

2020–2021 BOARD OF DIRECTORS James F. Holmes, Jr., MD, MPH President University of California Davis Health System

Angela M. Mills, MD Secretary Treasurer Columbia University

Amy H. Kaji, MD, PhD President Elect Harbor-UCLA Medical Center

Ian B.K. Martin, MD, MBA Immediate Past President Medical College of Wisconsin

Christopher R. Carpenter, MD, MSc Washington University in St. Louis School of Medicine Wendy C. Coates, MD Los Angeles County-Harbor -UCLA Medical Center Michelle D. Lall, MD Emory University Nehal Naik, MD George Washington University

Ava Pierce, MD UT Southwestern Medical Center, Dallas Jody A. Vogel, MD, MSc, MSW Denver Health Medical Center University of Colorado School of Medicine Richard E. Wolfe, MD Beth Israel Deaconess Medical Center/ Harvard Medical School

President’s Comments Time to Recommit to Emergency Care Research

A Picture Is Worth a Thousand Words: Utilizing Smartphone Technology in the Evaluation of ENT Emergencies

Spotlight Championing Older Adults in the Emergency Department – An Interview with Christopher R. Carpenter MD, MSc

A View of Infinity

Why It’s Important for My Patients to Know I’m a Doctor

21 Preview

Clerkship Directors in EM The Impact of COVID-19 on the EM Residency Application Process

Climate Change and Health The Climate Crisis in Hawai’i

Diversity and Inclusion We Took an Oath: The Physician’s Role in Use of Excessive Force by Law Enforcement

SGEM: Did You Know? Presentation of Spontaneous Coronary Artery Dissection in the Emergency Department

ED Administration & Clinical Operations Interfacility Load Leveling ED Admissions as a Strategic Solution to ED Boarding

SAEM Foundation’s Annual Alliance Is Investing in a Brighter Tomorrow for EM Through Research – Will You Join Them?

Expressing Gratitude to the 2021 Annual Alliance and Legacy Society Donors

Advice for Contract Negotiations from a Health Care Administrator Turned Physician - Part 2

Five Tips to Transform Medical Students and Residents into Self-Directed Learners

Ethics in Action COVID-19 Disclosure vs Patient Confidentiality: Wading Into Uncharted Ethical Waters

EM Physician Scientist Training Programs: Opportunities for Residents Committed to Careers in EM Research

Global Emergency Medicine COVID-19 Outbreaks Within Immigrant Detention Facilities

Why Should I Be Involved in RAMS? Reflections from the 2020-2021 RAMS Board

Medical Education Medical Educational Scholarship and MedEdPORTAL

Human Trafficking: Identifying and Treating Victims

The Virtual Educator Interview with a Technological Disruptor: Introducing Edutainment to the Medical School Classroom

Briefs and Bullet Points

Academic Announcements

Now Hiring

Wellness & Resilience Burnout, Moral Injury, Vicarious Trauma, PTSD and the COVID-19 Pandemic: A Year in Review

SAEM Pulse is published bimonthly by the Society for Academic Emergency Medicine,1111 East Touhy Ave., Ste. 540, Des Plaines, IL 60018. (847) 813-9823 Disclaimer: The views and opinions expressed in this publication are those of the authors and do not necessarily reflect the official policies, positions, opinions, or views of the Society for Academic Emergency Medicine or its members. © 2021 Society for Academic Emergency Medicine. All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any form or by any means without prior permission in writing from the copyright holder.

PRESIDENT’S COMMENTS James F. Holmes, Jr., MD, MPH UC Davis School of Medicine 2020–2021 SAEM President

Time to Recommit to Emergency Care Research

“Since its beginnings in 1988-89, SAEM has been the central location to support, promote, and present emergency research.”

For a variety of reasons, it became apparent to me early in my career that emergency research was vital. Not only did it satisfy my desire to answer questions but more importantly, new discoveries improve care for emergency department (ED) patients. I was very fortunate early in my career to have had excellent mentoring and SAEM grant support to develop my research skills — both necessary to a developing emergency researcher. From grant support to the many collaborations, SAEM has played a critical role in my career. Since its beginnings in 1988-89, SAEM has been the central location to support, promote, and present emergency research. That commitment continues today. SAEM recently convened a task force to develop a 10-year plan to enhance emergency care research. The task force indicated that “SAEM, as one of its core missions, must enable its members to create new knowledge.” The task force provided seven major recommendations on which SAEM should focus: 1) identifying and developing strategies to increase member funding, 2) developing the next generation of emergency researchers, 3) sustaining those currently engaging in emergency research, 4) promoting research at the annual meeting, 5) adding staff for research support, 6) increasing the visibility of our researchers, and 7) facilitating multicenter studies. Actions from these recommendations have been, and are continuing to be,

implemented. Unfortunately, COVID-19 has slowed research productivity at many centers, especially as nonCOVID-19 ED research was simply halted at many sites. Although the pandemic provided an additional subject to study, we have been slowed in much of our discovery. COVID-19 also slowed some of SAEM’s research activities. It is now time for both SAEM and our members to recommit to emergency research. As part of this recommitment, let me also encourage you to contribute to the SAEM Foundation (SAEMF). SAEMF is the largest emergency medicine foundation and provides over $500,000 annually in grants to our members. Primarily supporting junior investigators, over the years the SAEMF has supported numerous future research leaders in emergency medicine. I am increasing my commitment to become an Enduring Donor and urge everyone to donate at a level at which they are comfortable. Please visit the SAEM Foundation webpage for more information. With support from SAEM and SAEMF, and the dedication to research by our members, I look forward to the countless future discoveries that will impact the way we practice medicine in the emergency department. ABOUT DR. HOLMES: James F. Holmes, Jr., MD, MPH, is professor and vice chair for research in the department of emergency medicine at UC Davis School of Medicine.

SPOTLIGHT

CHAMPIONING OLDER ADULTS IN THE EMERGENCY DEPARTMENT An Interview With Christopher R. Carpenter MD, MSc Christopher R. Carpenter, MD, MSc, is professor of emergency medicine in the department of emergency medicine at Washington University in St. Louis. He is deputy editor-in-chief of Academic Emergency Medicine journal and associate editor of Annals of Internal Medicine’s ACP (American College of Physicians) Journal Club and the Journal of the American Geriatrics Society. Dr. Carpenter serves on the Society for Academic Emergency Medicine (SAEM) Board of Directors, the ACEP Clinical Policy Committee, and the Clinician-Scientists Transdisciplinary Aging Research Coordinating Center Leadership Core. Dr. Carpenter holds a Bachelor of Science in chemistry from Hope College, Michigan where he graduated cum laude in 1990. He graduated from Wayne State University School of Medicine in 1994 before fulfilling a military commitment with the United States Navy as a diving medical officer. In 1998, he began a five-year residency in emergency medicine and internal medicine at Allegheny General Hospital in Pittsburgh, serving as a dual chief resident during his final year. In 2003, he joined the emergency medicine faculty at Washington University in St. Louis with primary clinical duties at Barnes-Jewish Hospital. He earned a master’s degree in clinical investigation in 2007 through the Washington University Clinical Research Training Center. Dr. Carpenter’s primary emergency medicine research interests are geriatrics, cognitive dysfunction, evidence-based medicine, diagnostic testing, and implementation science and he has lectured globally on these topics. He has worked with collaborators internationally to improve the efficiency, experience, and outcomes of older adults from an episode of emergency department care. As the former chair of the SAEM Evidence Based Medicine (now Evidence-Based Healthcare and Implementation) Interest Group and ACEP Geriatric Section, he merged interests to coauthor the Geriatric Emergency Department Guidelines endorsed by the SAEM Board in 2014.

What led you to choose emergency medicine as your specialty and, specifically, why academics? As a first-year medical student I knew that I would be an interventional cardiologist. Wayne State had a program in the early 1990s where first-year medical students could observe in the emergency department on weekends. I signed up, showed up, and soon found myself working with individuals like Ronald Krome, who shared the young history of emergency medicine. Between the decision density of critical thinking mixed with the opportunities to contribute to the science of an emerging specialty, I was sold.

What inspired your interest and involvement in geriatric EM? Over the last 20 years, I have found that most geriatric emergency medicine champions have a personal story that catalyzed their interest. My awakening occurred during my first internship at Portsmouth Naval Medical Center. In February and June of that year, both my grandfather and grandmother experienced acute health crises that proved fatal (both unfortunately on their birthdays). As the only physician in my family, I was trying to navigate communication between my family and the emergency physicians by telephone from nearly 1,000 miles away. I was profoundly disappointed in the way both events transpired in terms of empathy, geriatric awareness, and personal interaction skills. I believed that emergency medicine could become more and started to contemplate that vision over subsequent years.

What other research topics get you fired up and why? My career took an unexpected detour when my K23 resubmission was not scored in 2011. I had served as a leader of the 2007 Academic Emergency Medicine consensus conference on knowledge translation and was knee-deep in writing the Geriatric Emergency Department Guidelines when I realized that clinical research and guidelines alone would never be sufficient to change practice. I became immersed in the concepts of implementation science and was invited to lead a NIH workshop developing a framework for “dissemination and implementation” science. Based on that NIH effort, I suggested that CONSORTlike reporting standards for implementation science were required to standardize efforts across fields. Then I was invited to Europe where colleagues across medical disciplines were creating those criteria, which ultimately became the Standards for Reporting Implementation Studies (StaRI) guidelines that are now required by numerous journals and grant mechanisms. Therefore, the nongeriatric emergency medicine topic that most interests me is the concept of getting from what we know to what we do with any research topic for any population or organ system. Since World War II the United States has spent billions of dollars funding researchers with profound impact on public health and patient outcomes, yet much of this knowledge remains buried on pages of a journal or as theory in a textbook collecting dust on a bookshelf. In 1999, the Institute of Medicine estimated that on average it takes 17 years for 14 percent of evidence to reach the bedside and as I review manuscripts, I am constantly striving to understand how investigators can build for implementation at the earliest stages. My best friend, Ken Milne, created the popular podcast Skeptics Guide to Emergency Medicine in a focused effort to reduce that knowledge decay and in recent years we have merged social media with traditional peer review via the monthly Academic Emergency Medicine Skeptics Guide to Emergency Medicine Hot Off the Press (SGEM HOP) podcast

Dr. Carpenter conducting research

and blog. Theorizing about knowledge translation is interesting, but SAEM provides opportunities to innovate and overcome barriers that others only contemplate. Funding, conducting, and reporting implementation science is complex and a work in progress, but in my opinion well worth the efforts and work in which SAEM is a leader.

I’m sure you’ve had many experiences in your career that have shaped you as a physician and person. Are there any in particular that stand out and, if so, why? Many memories good and bad jump to mind, but the one that I am reminded of on a weekly basis is rooted in my residency home Allegheny General Hospital. I received support from the United States Navy Health Professions Scholarship Program to pay for medical school, so I served three years on active duty after my initial internship in Virginia. I was young and adventurous so I naturally selected the Dive Medical Office program so I could learn hyperbaric medicine while proving my mental toughness with the Navy SEALs. Things did not work out as I’d envisioned because during “pool week” at the Naval Diving and Salvage Training Center in Panama City Florida I suffered scuba-related pulmonary barotrauma — twice. Disappointed and angry at myself, I finished my service commitment with the Marines in Yuma Arizona and turned my attention back to residency. I wanted to return home to Michigan but learned that the emergency medicine/internal medicine (EM/ IM) program at Wayne State University had closed. I applied to every EM/IM combined program and interviewed one cold winter day in Pittsburgh. I had never been to Pittsburgh and knew nobody in this Midwest town. The program director and program coordinator instantly made my wife and me feel like we were home — a feeling that continues to this day as I met some of my closest friends there. Allegheny General Hospital’s department of emergency medicine taught me to view my work colleagues as family, an approach that I carried with me to Washington University 18 years ago when we transformed a vision of an academically rigorous four-year residency into a reality. I try to remember that nervous Navy doc in a strange town that was me as we “adopt” a new family with each year’s resident class. My Washington University nurse and physician colleagues are family and continue to shape me as a physician and person. continued on Page 6

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What are the most significant changes or advances you’ve seen in emergency medicine in the past 20 years? Within emergency medicine who has not watched our specialty methodically and repeatedly address the challenges of COVID-19 with awe-inspiring pride? I have watched our SAEM members on national news explaining the essential public health responsibilities of physical distancing with social connectedness, masks in public, and immunization strategies, while balancing physician and nurse wellness despite the emotional turmoil underway. Emergency medicine adapted to COVID-19 with breathtaking efficiency, including contributions to understanding the basic pathophysiology and exhibiting healthy skepticism amidst a barrage of underdeveloped and non-peer-reviewed science on diagnostics and therapeutics. Emergency medicine’s response to the COVID-19’s global pandemic demonstrated to me that our specialty has arrived in that we know how to problem solve pragmatically — and other fields finally understand that often untapped potential of emergency medicine that ranges from the bench to the bedside and beyond.

What do you think are the most urgent issues facing emergency medicine in the U.S. today? I worry about the sustainability of academic medicine, including emergency medicine. So much of academia is built on altruism that is supported by clinical operations that have historically provided surpluses that permit time for innovative teaching, mentoring, peer reviewing for scholarly journals, and serving on committees, task forces, interest groups, and academies. As health care costs skyrocket and the goalposts for clinical revenue are continually moved by payers, the luxury of “academic time” is threatened. I don’t have pragmatic solutions for this threat. I do believe this is an urgent issue for SAEM and indeed all of academic medicine.

SAEM PULSE | MARCH-APRIL 2021

In the coming years, what will emergency medicine physicians need to become experts at?

I am quite biased here, but I believe emergency medicine physicians are already the experts in some facets of medicine that even they do not recognize — specifically acute diagnostics for life-threatening disease. We like to think of ourselves as proceduralists, best trained to intubate and resuscitate — and we are! However, much more frequently emergency medicine makes more mundane decisions about labs, imaging, and follow-up based on constellations of history and physical exam. Our non-emergency medicine colleagues see a finite spectrum of patients with subarachnoid hemorrhage (neurosurgery), acute myocardial infarction (cardiology), or sepsis (critical care), so they deem themselves as the experts to rule-in or rule-out those conditions. Emergency medicine sees the entire spectrum of patients in whom those conditions are a possibility, so better understands diagnostic research concepts like spectrum effect or incorporation bias. As health care expenses grow, I foresee an increasing need for emergency medicine to flex our intellectual muscle of diagnostics to reduce waste and educate other specialties about concepts like decision aids,

“the nongeriatric emergency medicine topic that most interests me is the concept of getting from what we know to what we do with any research topic for any population or organ system.” machine learning, and a hierarchy of diagnostic science that extends beyond mere accuracy. We already do this subconsciously every day, so we need to harness that diagnostic and prognostic expertise to create funding and leadership opportunities within federal funding agencies.

You have played many roles/served in many ways with SAEM over the years… Which experiences have been your favorites and why? In 2002, I attended my first SAEM meeting in St. Louis. I watched with awe as all of the living former presidents of SAEM lined up for a ceremony under the St. Louis arch. These were the individuals I had only read about in papers and textbook chapters, yet here they were shaking my hand and gladly answering my questions about SAEM’s past, present, and future. Their message about SAEM resonated with me: abundant opportunities to contribute meaningfully exist, so waste not want not. From my leadership roles with three consensus conferences to my contributions growing the SAEM Geriatric EM Task Force from interest group to thriving academy, and opportunities to steer our flagship journal to an unprecedented impact factor and Altmetric, those opportunities consistently appear on the horizon and are what brings me back to SAEM time and again, because tomorrow never knows.

How has being involved with SAEM benefitted you professionally? SAEM provided the foundation for my academic roots. At my first SAEM meeting, Michigan State University’s Mike Brown taught me of this new concept called “evidence based medicine” while running a workshop on diagnostic likelihood ratios. A few years later David Cone and Lowell Gerson invited me to join the Academic Emergency Medicine editorial board and then encouraged me to create a new series called “Evidence Based Diagnostics.” Soon thereafter, new Academic Emergency Medicine editor-in-chief Jeff Kline asked me to serve as deputy editor-in-chief and develop SAEM clinical guidelines, which became Guidelines for Reasonable and Acute Care in Emergency Medicine (GRACE). The byproduct of these SAEM experiences has been an accelerated research portfolio for my own scholarly activity, as well as many opportunities to serve on NIH and PCORI study sections. SAEM has been and remains a career accelerant that requires from me only ambition, time, and new ideas.

What three reasons would you give a resident who asks why he or she should join SAEM?

Dr. Carpenter at a luncheon with EM founding father, Peter Rosen, MD

1. Unique opportunities to experience the breadth of emergency medicine academia ranging from educators to researchers and bedside clinicians — our specialty’s scholarly leaders. 2. Early leadership opportunities, including RAMS, interest group and academy activities, and resident editor roles with two journals. 3. Inside scoop to the academic job market via events with chairs and fellowship directors.

How has the pandemic affected you, your practice, your family? What are the biggest challenges, greatest lessons, and richest rewards you’ve experienced during this time? Thankfully, my family in St. Louis and back home in Grand Rapids, Michigan have remained healthy during the era of COVID-19. Like many, my college-aged child has struggled emotionally and academically with the online learning mandated by the pandemic. Although not the college experience any of us envisioned, my family continues to adapt and will persevere despite these obstacles. The richest professional reward that I will remember for the rest of my career is seeing one SAEM colleague after another as I turned on the evening news and heard logic push back against fear. On a more personal note, I was thrilled to adapt Academic Emergency Medicine’s Evidence Based Diagnostics series in the early months of COVID-19 to scientifically report the shoddy science of SARSCoV-2 diagnosis and illuminate a better path forward. This work created opportunities at ACEP and the NIH to ensure contemplation around the potential harms and benefits of molecular, antigen, and imaging testing amidst a constantly shifting evidentiary landscape.

How is this COVID crisis different from other crises you’ve faced in the field? For me, the element of COVID-19 that keeps me awake at night is the threat to family health. As an emergency physician, I stepped forward to put myself in harms way but my wife and children did not. This constant threat to their health in conjunction with the canceled life events that can never truly be recovered (graduation, sports seasons, etc.) and continual uncertainty about a time frame for return to normalcy make COVID-19 unlike any professional threat I have ever faced or even anticipated.

Dr. Carpenter and family at Hope College, Holland, MI

Up Close and Personal Name one thing on your bucket list. Learn how to play the guitar What one word would you use to describe yourself? Conversely, what one word would your friends use to describe you? I would describe myself as persistent; my friends would describe me as fervent. What is one thing about you few people know? I ran 300m hurdles in high school (came within 0.1 seconds of my high school’s record) and 400m hurdles at Hope College where I won my first race of freshman year. I’d be worried about breaking my neck if I tried to run those hurdles now! If you couldn’t be in emergency medicine, what would be your alternate career? My father was a teacher, coach, and then superintendent. I tutored in college to help pay the bills and thoroughly enjoyed the moment when student’s eyes flew open as they finally understood a concept. I would probably have become a high school or college chemistry teacher and coach. What do you do to relax? Watch sci fi or superhero movies with my children who are now in college — and then debate plot twists! 7

21 PREVIEW

#SAEM21

Essential Event. Exceptional Value. Extraordinary Experience.

A Message From Daren M. Beam, MD, SAEM21 Program Committee Chair

ANNUAL MEETING PREVIEW

The COVID-19 pandemic has prompted a shift in the way we conduct our SAEM annual meeting, moving us from an in-person gathering to a virtual implementation. But in the resilient and determined spirit of emergency medicine, we have made the most of these unprecedented times to bring you an innovative and imaginative virtual SAEM Annual Meeting experience that you will remember long after COVID-19 has been vanquished.

Working with a leading virtual event platform, we’ve taken the most outstanding elements of our in-person annual meeting and reimagined them in innovative ways to create an energizing, engaging, fully interactive online experience above and beyond anything we’ve ever done before. This one-of-a-kind experience features everything you love about the SAEM Annual Meeting, and more, delivered to you in a fully virtual format: • High-quality, groundbreaking plenary abstract sessions • Interactive Q&A that lets you engage in robust scientific exchange • An inventive, interactive exhibit and symposia experience

• A lively and engaging residency and fellowship fair • A reimagined, first-of-its-kind virtual SonoGames! • Not one, but TWO inspiring keynote addresses from distinguished speakers • Virtual networking events to foster personal and professional connections • Opportunities to present your research, educational innovations, and didactics to a global audience • Cutting-edge research and dynamic didactics from the best minds in academic EM • Expert educational content from world-class faculty • Opportunities to cultivate collaboration with colleagues within the academic EM community • A few fun surprises! We look forward to gathering together in-person for SAEM22 in New Orleans; until then, we invite you to make yourself comfortable and enjoy first-rate educational content from the comfort of your own home or office! Thank you for your unwavering commitment to SAEM, academic emergency medicine, and the patients and communities you serve. On behalf of the SAEM Program Committee, we’re excited to have you join us as we present discovery, learn together, make new connections...and have some fun!

Abstracts present research data, including study background and methodology, research limitations and results, and the conclusions/significance of the study. The SAEM21 Program Committee is pleased to announce the top eight abstracts, as the best of the best, selected to be presented during special plenary sessions at the SAEM21 Virtual Annual Meeting.

Opening Session Plenaries

Wednesday, May 12, 10:00 AM – 11:00 AM CT 1. Integrated Omics Endotyping of Infants With Respiratory Syncytial Virus Bronchiolitis

Presenting author: Kohei Hasegawa, MD, MPH, Harvard Medical School/Massachusetts General Hospital

2. Impact of Race and Ethnicity on Emergency Medical Services Administration of Opioid Pain Medications for Injured Children Presenting author: Daniel Nishijima, MD, MAS, University of California, Davis

3. Effect of Losartan on Symptomatic Outpatients With COVID-19: A Randomized Clinical Trial

Presenting author: Michael Puskarich, MD, MS, University of Minnesota/Hennepin County Medical Center

4. Point-of-Care Ultrasound as a Rule-Out Test in Suspected Diverticulitis Reduces Emergency Department Length of Stay Presenting author: Lauren Ann Selame, MD

Thursday Session Plenaries

Thursday, May 13, 10:00 AM – 11:00 AM CT 5. Does Problem Representation by Third-Year Medical Students Increase Diagnostic Accuracy? (CDEM Sponsored) Presenting author: Jake Valentine, MD, Johns Hopkins Hospital

6. Emergency Visits for Nonfatal Opioid Overdose During the COVID-19 Pandemic Across Six United States Health Care Systems

Presenting author: William Soares, MD, MS, University of Massachusetts Medical School-Baystate Campus

7. Racial and Ethnic Disparities in the Prehospital Management of Nontraumatic Pain Presenting author: Angie Aceves, McGovern Medical School of UTHealth at Houston

8. Venous Thromboembolism in Patients Discharged From the Emergency Department With Ankle Fractures Presenting author: Keerat Grewal, MD, MSc, Mount Sinai Hospital Toronto

Register By March 15 and Save! Registration rates are the lowest they’ve ever been for a typical, in-person SAEM annual meeting, and if you register today, or any time before March 15, 2021, you’ll receive additional early bird savings!

Dr. Nathan Kuppermann to Present Inaugural Dr. Peter Rosen Memorial Keynote Address at SAEM21 Nathan Kuppermann, MD, MPH, the Bo Tomas Brofelt Endowed Chair and a distinguished professor in the department of emergency medicine at the UC Davis School of Medicine, has been selected to deliver the society's Nathan Kuppermann, MD, MPH first-ever Dr. Peter Rosen Memorial Keynote Address, established in honor of emergency medicine's founding father who passed away in 2019. Dr. Kuppermann’s address, “The Kids Have Grown Up: The Rise of Academic Pediatric Emergency Medicine through Collaborative Research Networks,” will be presented on Wednesday, May 12, from 9:30–10 a.m. CT, during the SAEM21 Virtual Annual Meeting, immediately preceding the plenary session.

ANNUAL MEETING PREVIEW

Plenary Abstracts

Over the past few decades, the evidence generated to guide the care of acutely ill and injured children in emergency departments (EDs) globally has transitioned from retrospective case reports to large prospective research studies. This has further evolved into large, well-organized and well-funded pediatric emergency care (PEC) research networks. Not only are there two such networks in the United States, but similar networks exist in Canada, Europe, Australia and New Zealand. These networks have not only generated high-grade, precise and generalizable evidence on which to base care of acutely ill and inured children, they have also organized the implementation of this evidence to the bedside. Both pediatric and general emergency physicians have participated collaboratively in PEC research networks and there are lessons learned for all emergency care practitioners.

ACGME's Dr. Eric Holmboe to Present Thursday Keynote Address

ANNUAL MEETING PREVIEW

Eric S. Holmboe, MD, senior vice president, Milestone Development and Evaluation for the Accreditation Council for Graduate Medical Education (ACGME), will present a keynote address, “Achieving Desired Outcomes Eric S. Holmboe, MD in Graduate Medical Education: A Look Back and Forward,” on Thursday, May 13, 9:30–10 a.m. CT during the SAEM21 Virtual Annual Meeting. The plenary will review lessons learned from the early years of competency-based medical education (CBME), the first six years of Emergency Medicine Milestones use, and recently introduced learning analytics. The session will conclude with a discussion about the next steps needed to realize the full promise of outcomes-based education.

The launch of the Outcome Project in 2001 officially marked the beginning of competency-based medical education (CBME) in the U.S. The six general competencies of CBME provide an important framework that define key educational outcomes for physicians. CBME makes explicit the intense developmental process involved in becoming a specialist, which necessitates training programs that use the key educational principles of professional development to reexamine curricular design and approaches to assessment. To address the challenges of implementation and transformation, this plenary will review lessons learned from the early years of CBME, the first six years of EM Milestones use, and recently-introduced learning analytics. The session will conclude with a discussion about the next steps needed to realize the full promise of outcomes-based education.

Educational Sessions Advanced EM Workshop Day Tuesday, May 11, 9:00 AM – 6:00 PM CT

Advanced EM Workshop Day features intensive educational sessions that focus on particular techniques, skills, and practical aspects of the specialty. This year’s Advanced EM Workshop Day offerings include more than a dozen half- and full-day sessions that cover specialized areas in emergency medicine and strengthen knowledge and skills in specific topic areas. Add any of the below workshops to your schedule when you register for SAEM21. • The Opioid Crisis and Children: How to Manage Pain and Protect Them From Harm (Pediatric EM Interest Group Sponsored) • Critical Strategies in Simulation Procedural Skills Training for High-Risk/Low-Frequency Procedures (Simulation Academy Sponsored) • Clerkship Director Boot Camp (CDEM Sponsored) • Academic Wilderness Medicine Education (Wilderness Medicine Interest Group Sponsored) • Improve Your Educational Research: Medical Education Research Boot Camp • It’s Virtually Possible: Take Charge of Microaggressions in Academic Medicine • “The Wise Build Bridges While the Foolish Build Barriers”: Another Lesson from the Black Panther (ADIEM and Simulation Academy Sponsored) • Emergency Department Operations On-ramp: A Crash Course for New Medical Directors, Administrators, and Researchers (ED Administration and Clinical Operations Committee and Operations Interest Group Sponsored) • SAEM Grant Writing Workshop (Research Committee Sponsored) • SAEM Consensus Conference — From Bedside to Policy: Advancing Social Emergency Medicine and Population Health through Research, Collaboration, and Education (Social EM and Population Health Interest Group Sponsored) • Physician Advocacy Boot Camp: Creating Change Beyond the Emergency Department • Building an Academic Department Within a Corporate Structure • When to Say Yes and How to Say No: Leveraging Passion in an Academic Career (AWAEM Sponsored) • Clerkship Directors in Emergency Medicine (CDEM): The Art of Writing Effective Multiple-choice Questions (CDEM Sponsored) • Take and Bake: Low-Cost Simulation Models and Techniques Taught By the Pros (Simulation Academy Sponsored) • Be the Best Teacher: Clinical Teaching Educational Boot Camp • Adding a Climate Lens to Academic Emergency Medicine (Climate Change and Health Interest Group and Wilderness Medicine Interest Group Sponsored) • Stats and Research for the Rest of Us (Research Committee Sponsored) • Using Simulation to Promote DEI in Residency

ANNUAL MEETING PREVIEW

Didactics

Wednesday, May 12, 8:00 AM – 6:20 PM CT Thursday, May 13, 8:00 AM – 6:20 PM CT Friday, May 14, 8:00 AM – 12:50 PM CT Didactics are presentations that are designed to teach on a particular subject and can vary in structure from lecture and flipped classroom formats to panels and small group discussions. More than 100 innovative and interactive sessions cover a range of educational topics in key categories, including: administrative, career development, education, clinical, research.

IGNITE!

Wednesday, May 12, 1:00 PM – 2:50 PM CT Friday, May 14, 10:00 AM – 11:50 AM CT IGNITE! talks are fast-paced, highly energetic, captivating, and engaging presentations on a variety of topics. The IGNITE! format is five minutes in length with 20 auto-advancing slides. A panel of judges selects a “Best of IGNITE!” winner from each IGNITE! session. An “Audience Choice Award” is also given at each session based on audience polling. All topics are accepted. Speakers in the past have talked about their experiences in disaster relief, waxed poetic about the role of machine learning in emergency medicine and challenged core practices in EM critical care and education.

Innovations

Wednesday, May 12, 2:30 PM – 3:50 PM CT, 4:00 PM – 4:50 PM CT Thursday, May 13, 11:00 AM – 11:50 AM CT, 1:00 PM – 1:50 PM CT, 5:00 PM – 6:20 PM CT Friday, May 14, 9:00 AM – 10:20 AM CT Innovations present novel ideas, new products, innovative procedures, and unique approaches in medical education, faculty development, wellness, operations, and patient care. Innovations are presented in either a seven-minute oral presentation or as a tabletop/hands-on demonstration.

Forums SAEM Leadership Forum

Tuesday, May 11, 9:00 AM – 5:00 PM CT Add this forum to your SAEM21 Registration at no additional cost! The SAEM21 Leadership Forum provides exposure to core leadership topics with an emphasis on experiential learning and practical application. The SAEM21 Leadership Forum is designed for all levels of aspiring leaders who are interested in improving their leadership skills. The session will provide exposure to core leadership topics with an emphasis on experiential learning and practical application. Presenters are recognized experts with extensive leadership experience. The agenda includes segments on emotional intelligence and its impact on leadership style, strategies for successful leadership, increasing visibility, and managing conflict.

Junior Faculty Development Forum Tuesday, May 11, 9:00 AM – 4:15 PM CT

Add this forum to your SAEM21 Registration at no additional cost! The SAEM21 Junior Faculty Development Forum is an opportunity for early-career faculty to engage with senior leaders in emergency medicine to develop strategies for promotion, productivity, and academic advancement. The forum is designed to enable junior faculty to engage with senior leaders in our field, to develop strategies for promotion, productivity, and academic advancement, and to enable them to become the next generation of leaders in our field. It is intended for fellows and early-career faculty who have recently secured faculty positions within academic emergency departments. The forum will feature focused didactic presentations from leaders in EM administration, education and research, as well as a Q & A panel of current and former Department Chairs.

Chief Resident Forum

Thursday, May 13, 1:00 PM – 5:00 PM CT Add this forum to your SAEM21 Registration at no additional cost! The SAEM21 Chief Resident Forum features didactic presentations, interactive sessions, panel discussions, and networking sessions with fellow resident leaders and established senior leaders in emergency medicine administration, education, and research. The Chief Resident Forum is the preeminent opportunity for rising chief residents in emergency medicine to gain the skills to successfully lead their residency programs. The forum gathers chiefs from around the nation to discuss traits of effective leaders, network with peers, and get a crash course on keeping their residency thriving. Engaging sessions by national leaders emphasize the practical aspects of being chief, including optimizing resident schedules, developing innovative curricula, recruiting the program’s next generation, and balancing wellness with leadership.

SAEM Education Summit

Wednesday, May 12, 1:00 PM – 5:00 PM CT Add this forum to your SAEM21 Registration at no additional cost! The SAEM21 Education Summit is a half-day track devoted entirely to medical educators. This free-to-attend, special track is designed to help improve your education knowledge and expertise ranging from bedside teaching to education research provided by internationally-recognized experts in medical education. This session will include a mix of TEDMED-style presentations, lectures, panels, and small group workshops. Attendees will learn about evidence-based and cutting-edge medical education topics, how to be an effective education researcher, and strategies for increasing productivity while maintaining work-life balance.

Featured Events Speed Mentoring

Wednesday, May 12, 3:30 PM – 5:20 PM CT Add this event to your SAEM21 Virtual at no additional cost. SAEM21 Speed Mentoring matches residents and medical student mentees into small groups of 5-10 attendings, who share their interests, for quick-fire, 10-minute mentoring sessions. Participants will have an opportunity to start new mentoring relationships with mentors from around the country as well as socialize with fellow residents and medical students

Medical Student Symposium

Thursday, May 13, 9:00 AM – 4:00 PM CT

ANNUAL MEETING PREVIEW

Add this forum to your SAEM21 Registration at no additional cost!

The SAEM21 Medical Student Symposium provides an overview of emergency medicine and in-depth information about the process of applying for an emergency medicine residency position. A networking lunch with emergency medicine program directors and clerkship directors is included. The SAEM21 Medical Student Symposium (MSS) will include an overview of emergency medicine (EM) as a career choice and will discuss the residency application process for students with allopathic, osteopathic, international, and military backgrounds. This day-long symposium, presented by thought leaders in the specialty, will include specific discussions about clerkships, away rotations, personal statements, the match process, and interviews. There will also be ample time for questions and discussions during a lunch with EM program directors and clerkship directors. The SAEM Residency and Fellowship Fair, which showcases residency and fellowship programs from across the nation, will immediately follow the MSS and is part of the registration fee for this session.

SimWars

Wednesday, May 12, 1:00 PM – 5:00 PM CT SimWars is an entertaining, educational, simulation-based competition in which teams of clinical providers face off in timed, interactive scenarios to demonstrate their clinical skills, teamwork, communication, and problem-solving abilities. SAEM’s Simulation Academy SimWars is THE premier national simulation competition for emergency medicine residents.

Friday, May 14, 9:00 AM – 1:00 PM CT SonoGames® is an innovative, game-style approach to emergency medicine ultrasound education in which residency teams representing more than half of all emergency medicine residencies in the country, face off in an energetic competition that demonstrates their hands-on skills, knowledge of pointof-care ultrasound, and clinical decision-making abilities.

Clinical Images Exhibit Open daily during SAEM21

ANNUAL MEETING PREVIEW

SonoGames®

The SAEM Clinical Images Exhibit displays the most original, high-quality clinical images relevant to the practice of emergency medicine selected from more than 120 submissions.

Residency & Fellowship Fair RAMS Trivia

Wednesday, May 12, 6:30 PM – 7:30 PM CT Presented by Hambone’s Trivia, SAEM’s first-ever RAMS Trivia is an entertaining, immersive, live-hosted video event unlike any trivia game you’ve ever experienced before! So, gather your group of 4-6 trivia whizzes for four fun-filled, fastpaced rounds of trivia and lots opportunities to network. Sign up is free!

Speed Mentoring for Medical Educators

Thursday, May 13, 11:00 AM – 11:50 AM CT Add this event to your SAEM21 Virtual at no additional cost. SAEM21 Speed Mentoring for Medical Educators offers faculty an opportunity to engage in short discussions with mentors who have the expertise and significant experience in medical education. Participants will have an opportunity to sample potential mentoring relationships and identify a medical education mentor whose experience and personality aligns with their professional interests, desired career trajectory, and personality traits.

SAEM Jeopardy 2021: COVID-19 Edition Thursday, May 13, 6:30 PM – 7:20 PM CT

The focus of this year’s SAEM Jeopardy 2021 is COVID-19 and its impact as viewed through a sex, gender, and diversity lens. Categories will include biological sexbased differences associated with mortality risk as well as medications and vaccinations. Gender- and diversity-oriented questions will highlight how certain populations have been disproportionately affected by the pandemic in relationship to both mortality and collateral damage. The goal of the game is to engage and educate academic colleagues about the importance of considering sex, gender, and diversity in their research, teaching, and clinical care. Sponsored by ADIEM, AWAEM, and Sex and Gender in Emergency Medicine Interest Group.

May 3 – 6 and July 26 – 29, 2021 Included with your SAEM21 registration. Sign up starting March 1, 2021! The SAEM/RAMS Residency & Fellowship Fair is an opportunity for medical students and residents to explore residency and fellowship programs from across the nation, meet current residents and fellows, ask questions, and seek application and interview advice. You’ll have an opportunity to meet online with representatives from dozens of coveted residency and fellowship programs from around the country — all waiting to video conference with you in real time about their programs. What’s more, because this event is included with your SAEM21 registration, you will be able to sign up for and explore as many programs as you’d like! SAEM/RAMS is excited to provide residents and medical students with this convenient and costeffective career-building opportunity!

Program Registration is Open for the 2021 Residency & Fellowship Fair! The SAEM/RAMS Residency & Fellowship Fair is an important and prominent event in the annual emergency medicine application cycle, giving institutions the opportunity to showcase their residency and fellowship programs to medical students and emergency medicine residents looking to find their perfect residency or fellowship. Our first virtual event attracted an astounding 7,000 attendees! The response was so positive we’re offering TWO Residency & Fellowship Fairs in 2021! Program registration is open!

2021 Society for Academic Emergency Medicine Consensus Conference

From Bedside to Policy: Advancing Social Emergency Medicine and Population Health Through Research, Collaboration, and Education ANNUAL MEETING PREVIEW

April 13, 1:00-3:00 PM CT

April 27, 1:00-3:00 PM CT

Emergency departments (EDs) disproportionately care for vulnerable and underserved communities and are uniquely situated to be at the forefront of screening and referral for social risk factors (otherwise known as social determinants of health or SDoH) such as unstable housing, food insecurity, and interpersonal violence. Social emergency medicine is a growing field that emphasizes the importance of SDoH in the evaluation and management of patients, and communities, in the ED. The purpose of the SAEM21 Consensus Conference, “From Bedside to Policy: Advancing Social Emergency Medicine and Population Health Through Research, Collaboration, and Education” is to propel the field of social emergency medicine forward and address ways in

May 11, 2:00-6:00 PM CT

which emergency medicine can more effectively identify and intervene to address social needs. Led by a diverse group of content experts, researchers, policymakers, and other key stakeholders, the goals of this conference are to: 1. i dentify best practices, clarify knowledge gaps, and prioritize research questions; 2. b ring together key stakeholders with varied backgrounds to develop networks so that we may more efficiently collaborate on research priorities; and 3. d isseminate findings of the consensus conference through peer-reviewed publications, national meetings, policy briefs, and other venues.

EXHIBIT HALL OPEN Tuesday, May 11 6:00-7:00 PM CT Renee Hsia, MD, MSc

Joneigh S. Khaldun, MD, MPH

Karin Rhodes, MD, MS

In addition to breakout group planning sessions and a consensus-building process, the conference will include state-of-the-art didactics led by nationally recognized keynote speakers: • Renee Hsia, MD, MSc, professor of emergency medicine and health policy at the University of California San Francisco • Joneigh S. Khaldun, MD, MPH, chief medical executive and chief deputy director for health in the Michigan Department of Health and Human Services (MDHHS) • Karin Rhodes, MD, MS, chief implementation officer at the Agency for Healthcare Research & Quality (AHRQ) The conference will result in a social emergency medicine research agenda that supports future interdisciplinary research at the intersection of social context and emergency care. Add this workshop to your SAEM21 registration at no additional cost.

Sharpen Your Stroke Care Knowledge!

Wednesday, May 12 8:00-9:00 AM & 12:00-1:00 PM CT

ANNUAL MEETING PREVIEW

SAEM21 Virtual Exhibit Hall

Thursday, May 13 8:00-9:00 AM & 12:00-1:00 PM CT Friday, May 14 9:00 AM-1:00 PM CT – Exhibit Hall Open

Sponsors and Exhibitors... SAEM21 Is Your Chance to Connect With EM’s Top Decision Makers SAEM’s engaging and interactive virtual exhibit hall format is designed to drive more attendees to your virtual exhibit booth and increase attendee/exhibitor engagement. Reserve your exhibit booth today for an opportunity to engage with these thought leaders, innovators, and early adopters in emergency medicine. For details and additional opportunities, including sponsorships, see the SAEM21 virtual meeting prospectus or contact John Landry: (847) 257-7224.

Translating Knowledge into Practice

Announcing www.StrokeJourney.com - a new interactive educational resource for all healthcare professionals involved in stroke management from the pre-hospital environment through outpatient care. Our fast-growing library delivers compact, concise, and clinically relevant modules to provide evidence-based answers quickly.

Sharpen Your Stroke Care Knowledge at StrokeJourney.com! A fast-growing education library delivering clinically relevant modules

What Should We All Know about “Potential Stroke” Patients in the ED Endovascular Therapy in COVID with Limited Announcing History and Impaired StrokeJourney.com - a new interactive educational resource for all healthcare professionals involved in stroke Patients? through outpatient care. Communication – What Do You Do? management from the pre-hospital environment Our fast-growing library delivers compact, concise, and clinically relevant modules to provide evidence-based answers quickly. TO THIS PODCAST NOW Select a stroke stage from the homepageLISTEN and the site lists related education modules like these:

WATCH THIS VIDEO NOW

Access free CME certiﬁed and non-certiﬁed videos, podcasts and slides anytime on any device. Check back often for new content! The National Stroke Education Center (NSEC) created The Stroke Journey to leverage multiple digital education strategies that provide up-to-date stroke resources and a CME-accredited learning platform for physicians, nurses, pharmacists, and allied health clinicians. NSEC was formed by an internationally recognized team of stroke educators from the University of Cincinnati Department of Emergency Medicine, along with experts in stroke care and research from across the United States.

CLERKSHIP DIRECTORS IN EM

The Impact of COVID-19 on the EM Residency Application Process

SAEM PULSE | MARCH-APRIL 2021

By Julianna Jung, MD, on behalf of the SAEM Clerkship Directors in Emergency Medicine academy

On New Year’s Eve the nation collectively heaved a sigh of relief, thankful that one of the hardest years in recent history had finally ended. The winter surge in COVID-19 cases had put an unprecedented strain on our hospitals, leaving emergency medicine (EM) physicians drained, and sentencing us to a year of lonely Zoom-based holidays. The release of the COVID-19 vaccine was a bright spot in a dreary time, bringing hope of a return to normalcy. With many EM physicians vaccinated, we finally had something to celebrate with our champagne toasts at the end of 2020. However, in the cold light of January, we must face the reality of our ongoing challenges. Vaccine rollout has been far slower than we might have hoped, and vaccination status doesn’t change social distancing or masking guidelines — dashing our dreams of in-person gatherings and seeing the smiling faces of our loved ones. In medical education, our dreams for 2021 have similarly not been realized. We all hoped that 2020

was an “exceptional year,” never to be repeated, but now we face the grim reality that the pandemic will continue to impact medical students in their quest to become EM physicians. In late January, the Coalition for Physician Accountability (CoPA) released a position statement on the 2021 application year. The statement stipulated that prior to August 1, away rotations should be limited to “orphan” students or those who have no residency program in their chosen specialty at their medical schools. After August 1, away rotations may be permitted for all students; however, a limit of one per student was recommended, and the timeline may change based on how the pandemic progresses. With the emergence of new strains of COVID-19 and the very real challenges of mass vaccination, it is in no way certain that we will be in a better place come August. So how does this impact EM? The struggle is real! Our specialty

relies heavily on away rotations, and pandemic restrictions impact every aspect of the transition from medical school to EM residency. For students, limiting away rotations reduces learning opportunities and exposure to the field. This translates to interns who are less prepared for their new roles and are potentially not even a good fit for EM. On the medical school side, it wastes educational capacity, leaving rotation spots empty. And for residency programs, it impairs recruitment efforts and reduces the quality and quantity assessment data for screening and selection of applicants. Despite the adverse effects, these regulations are necessary for safety, and we are bound to follow them. Though the majority of EM physicians are vaccinated, the availability of COVID-19 vaccine for medical students has been highly variable. The vaccine is also only 95% effective, leaving one person in 20 unprotected. Institutional policies governing the availability of away rotations are also variable, as

“In addition to maximizing rotation opportunities for students, it is critical that we think carefully about fairness and equity in the residency application process.” are state regulations regarding travel and quarantine requirements. Students themselves may have legitimate health issues that place them or their household members at particular risk in the event of COVID-19 exposure. For all these reasons, it is difficult to imagine a way to implement widespread visiting rotations for medical students in a safe and appropriate manner until the pandemic is well controlled. So what can we do as EM leaders to mitigate the damage to our learners and our programs?

First and foremost, be safe.

As much as we all want to resume our normal educational operations, it is our responsibility to follow all relevant guidelines and restrictions in the interest of public health.

Advocate for “orphans.”

COVID-19 restrictions have created classes of “haves” and “have-nots” among EM-bound students. Some students have two or more affiliated EM programs at their institutions, giving them access to robust advising and multiple rotations; other students have none, placing them at a disadvantage in the residency application process. We can all seek out “orphan” students in our regions and invite them to rotate. If our institutions prohibit or restrict outside rotators, we can petition leadership to make exceptions for students in dire need.

Fight for diversity!

Unsurprisingly, the educational impact of COVID-19 has not been distributed equitably across demographic groups. Students of color are more likely to fall into the “orphan” category and thus lack access to EM experiences, and none of our nation’s historically black medical

schools have affiliated EM residency programs. We can help mitigate disparity by advocating with our institutions to provide rotation opportunities (and scholarship funding) for these students, and by banding together with other nearby institutions to “adopt” local orphan schools to ensure that students’ need are met.

Maximize opportunity.

There will be A LOT of students looking for rotations after August 1, so now is the time to start figuring out how to accommodate them all. We can look at options for increasing availability of rotation spots at our institutions, considering new clinical sites and new ways of integrating students into our teams.

Get the word out.

Many rotation spots went unfilled in 2020. The reasons for this are numerous, but lack of information was one major barrier. We can all post open spots for students on the listserv, reach out to nearby institutions, and talk with colleagues around the country. We don’t currently have a cohesive system for tracking rotation availability and COVID-19 restrictions nationwide, but if anyone reading this has a knack for databases and would like to spearhead a really great project, please reach out! In addition to maximizing rotation opportunities for students, it is critical that we think carefully about fairness and equity in the residency application process. No matter what regulations and guidelines are put in place, we will never succeed in completely leveling the playing field. Some students will inevitably have better access to EM rotations than others. And most students will abide faithfully by the rules, while a few

will ignore them and do whatever they want. These factors are certain to create inequities in residency applications, with some students having multiple EM rotations and letters and some having only one. It is imperative that we review applications holistically and refrain from viewing students with more robust EM experiences more favorably than those with fewer opportunities. To do otherwise would at best disadvantage students who, through no fault of their own, have limited access to EM. At worse, it would reward students who engage in inappropriate behavior, disregarding rules and the needs of others in the service of their own self-interest. In summary, we can use our power as EM leaders to advocate for the needs of EM-bound students, thus benefitting not only the students themselves, but also our clerkships and our residency programs. In doing this, we must recognize that even our best efforts cannot eradicate inequities, and we need to consciously moderate our expectations of students as the pandemic drags on for another year. Until then, we can dream of a New Year’s toast to a return to normalcy in 2022!

ABOUT THE AUTHORS Dr. Jung is an associate professor of emergency medicine and director of medical student education in the department of emergency medicine at Johns Hopkins University School of Medicine. She is the 2020-2021 president of SAEM’s Clerkship Directors in Emergency Medicine (CDEM) academy.

About CDEM Clerkship Directors in Emergency Medicine (CDEM) represents the interests of undergraduate medical educators in emergency medicine. It serves as a unified voice for EM clerkship directors and medical student educators and provides a forum for them to communicate, share ideas, and generate solutions to common problems. For more information, visit the CDEM webpage. As an SAEM member, you may now join as many academies* and interest groups as you choose. Just log into your member profile and click on the "Update (+/-) Academies and Interest Groups" button.

CLIMATE CHANGE AND HEALTH

The Climate Crisis in Hawai’i By Anna Brandes and Caitlin Rublee, MD, MPH, submitted on behalf of the SAEM Climate Change and Health Interest Group

SAEM PULSE | MARCH-APRIL 2021

Last November, I was driving around the east side of Oahu along Kamehameha Highway with my dad. It was a beautiful day, sunny with some heavy clouds along the Ko’olau mountains, waves crashing along the shore and turquoise blue water all the way to the horizon.

“Anna, you see this road we’re driving on?” my dad asked. “This is one of the most at-risk roads on the island and in the state of Hawaii.” My dad was a civil and ocean engineer at the University of Hawaii, and one of the most recent projects he had been working on was assessing the vulnerability of coastal roads to sea level rise. Sea level rise from anthropogenic climate change was something we talked a lot about. Extreme heat, sea level rise, and other extreme weather events are not just distant threats but

“Extreme heat, sea level rise, and other extreme weather events are not just distant threats but something the state of Hawaii and many people around the world face today. ” something the state of Hawaii and many people around the world face today. It was something my dad, who was diagnosed with metastatic pancreatic cancer during my third year of medical school, was still thinking about, as cancer and chemotherapy ravaged his body. I could tell he hated leaving this problem to future generations — especially my sister and me.

What struck me on that particular day as we drove through Ka’a’awa was just how close the houses were to the road. When I asked my dad about it, he told me that if rising greenhouse gas emissions followed even the intermediate risk scenarios as projected by the Intergovernmental Panel on Climate Change (IPCC), the houses and families living in them would be seriously

“After surviving decades of colonial land laws, resisting land grabs from developers, and existing in an area where property values continue to soar, the ocean — one of the most culturally significant aspects of living in this area — could be the most pressing threat to their livelihoods.” threatened. What bothered me most was the fact that so many of the houses along that particular stretch of highway are low-income, often native Hawaiian, multigenerational family homes. After surviving decades of colonial land laws, resisting land grabs from developers, and existing in an area where property values continue to soar, the ocean — one of the most culturally significant aspects of living in this area — could be the most pressing threat to their livelihoods. I thought about my medical training and all of the health threats and ties to the environment; I thought about the physicians who practice on the island, even if just for a rotation during residency. As is the case right here in my community, the climate crisis is a global public health emergency. The United States National Climate Assessment describes key health threats to Hawai’i and other Pacific islands. Loss of biodiversity, vector-borne diseases, flooding and climate-related disasters, urbanization, contamination of freshwater

aquifers, threatened fish species and altered marine ecosystems are now realities. Our health systems are already feeling the burdens of climate change and sea level rise, but so are individual people. What if a particularly high tide caused flooding in Ka’a’awa where the road and houses along it rise just a few feet above sea level? And what if somebody living along the road had medical concerns like my dad’s and needed to make it to the nearest trauma center? Would there be time? These are the questions we must ask ourselves as trainees and emergency physicians. As a soon-to-be physician, I believe it is my duty to use the privilege that comes with such a title to advocate, through climate action, for patients like the ones living in Ka’a’awa and other lowlying coastal areas. Fortunately, work has already started in Honolulu linking climate change and equity and implementing policies to adapt and build resilience to local threats; but, this is only just the beginning of safeguarding health and

the cultural richness in Hawai’i and other nations. While my dad is no longer here to see the ways in which his research will continue to shape the future, I vow to carry on his work as a physician and patient advocate. I hope you will join me.

ABOUT THE AUTHORS Anna Brandes calls Hawaii home and is currently a medical student at the University of Utah interested in the intersection of climate change and human health. r. Rublee is an assistant D professor of emergency medicine at the Medical College of Wisconsin and chair of the SAEM Climate Change and Health Interest Group. She did an elective rotation in Honolulu during residency.

DIVERSITY AND INCLUSION

We Took an Oath: The Physician’s Role in Use of Excessive Force by Law Enforcement

SAEM PULSE | MARCH-APRIL 2021

By Anisha Turner, MD; Sarah Shafer, MD; and Richina Bicette, MD, on behalf of SAEM’s Academy for Diversity & Inclusion in Academic Emergency Medicine

As physicians in a county hospital in Houston, Texas — one of the most diverse cities in America — the vast majority of our patients are Hispanic, African-American, or CaribbeanAmerican. Our position in the community carries with it the responsibility of not only treating illness, but also being a pillar of strength and a voice for those who are unable or unwilling to speak for themselves. Unfortunately, we have not always been able or willing to use our voices to advocate for those who may have been victims of excessive force by police officers.

and the controversial police shootings of Jacob Blake and Rayshard Brooks, amongst others. Fueled by deep wounds inflicted upon them by this nation’s legacy of racism and injustice, minorities, gathered to engage in mostly peaceful protests, became the intended targets of rubber bullets from police officers using force to arrest citizens for using their voices to demand change. Emergency department (ED) beds filled with patients with chemical burns, abrasions, and shattered femurs — all results of their interactions with the police.

We’ve all seen the video newsclips of law enforcement using excessive force (UOEF) against minorities — during the protests that followed the untimely and unnecessary death of George Floyd

What happens when such a patient sits on an ED gurney, handcuffed to the bed, with two officers by his side? Do we ask the difficult questions about an officer’s use of force? Do we document

our concerns? Do we in any way confront and report suspected cases of UOEF? Unfortunately, all too often, the answer is no. And it appears we are not alone. In one survey of 300 physicians, even when law enforcement UOEF is suspected, it is not commonly reported or documented. Why is UOEF on police detainees treated differently than other forms of abuse, such as child abuse, elderly abuse, and sex trafficking? Power imbalances are inherent to abusive dynamics, and this remains true in the relationship between law enforcement officers and detainees. Yet, police brutality differs from other forms of abuse in that law enforcement officers operate under the authority of governing

bodies, leaving prisoners with little recourse against UOEF. While, in previous years, reported incidents were based on mere accusations; recent widespread availability of recording equipment has provided some measure of objectivity to these scenarios. Nevertheless, there are numerous physician barriers that can be cited for the absence of reporting and documenting of UOEF by law enforcement officers; these include lack of training, concern for malingering, patient ability to cooperate during evaluation, and a lack of standardized guidelines for reporting incidents. Additionally, police officers and ED physicians share an essential, reciprocal relationship that cannot be undervalued. Police officers are vital in administering aid to our patients in the field, directing them to the ED for higher level of care, contributing crucial information to assure quality care, and providing safety from violent individuals to staff and other patients. Lastly, we are not present to assess situations in the field and

may not be prepared to determine the appropriateness or justification of police use of force. Regardless, these factors are not justification for our neglect. As physicians, we are called to be powerful advocates for the sake of vulnerable patients, detainees included. Moving forward, we propose the implementation of several action items for addressing patients suspected of law enforcement UOEF

Uphold the patient’s autonomy, rights and privacy.

Realize that prisoners are a vulnerable population affected by the power dynamic between a detainee and correctional officer. Remember that in the ED, the prisoner assumes the role of a patient and deserves the autonomy, rights, and privacy as such. Question the patient without the power authority in the room. If you desire a chaperone, ask your hospital’s peace officer or nursing staff to accompany you. Also, listen and take the patient seriously. It is not your job to be an investigator, but it is your job to

gather pertinent information objectively to protect both parties involved.

Document. Document. Document.

From day one of residency we are taught that proper documentation is key to excellent patient care. Document both histories objectively. Also, document instances of police brutality with proper ICD-10 codes so episodes of violence can be collected and researched as epidemiological data.

Commit to help.

If a detainee reports UOEF, inform him or her that you are documenting the concern. Consider reporting any inconsistency or concern to the police department’s internal affairs office. Additionally, you can encourage the detainee to follow the police department’s grievance procedures.

continued on Page 22

DIVERSITY AND INCLUSION

continued from Page 21

Commit to act.

Make a commitment to act on both an institutional, state and national level. Develop medical education for addressing patients suspected of being subjected to law enforcement UOEF. Engage with police agencies and policymakers to assist them in their move toward evidence-based practice. Be available for legal proceedings. Encourage your institution to offer training courses to prepare physicians to become street medics — providers trained to treat patients injured in conflicts with police and large crowds. Employ physician members of ICE Rapid Response teams, which are teams that are in areas where immigrant enforcement activity is suspected. Work with your institution or national organization to develop legal and professional guidelines and protocols for addressing police brutality.

Actively fight to combat your own prejudices.

SAEM PULSE | MARCH-APRIL 2021

While it is easy to point fingers and criticize police officers, physicians deal with all the same injustices and inadequacies in the hospital; for example, how race influences the decision to utilize restraints on a patient.

Although emergency medicine physicians are not adequately prepared to determine the appropriateness or justification of police use of force, we should not ignore suspicions. We should, instead, use our position as patient advocates to draw attention to cases that may require further investigation. This is the same position of advocacy that we take in regard to current practices of reporting. While it is not our job to decide whether a crime has occurred, it is our job to make sure we are doing our due diligence to protect the patients we are sworn to serve. Respect your oath and do your job.

ABOUT THE AUTHORS Dr. Shafer is an assistant professor of emergency medicine physician and medical toxicology at Baylor College of Medicine. Dr. Bicette is an assistant professor of emergency medicine at Baylor College of Medicine and a medical director in the Baylor St. Luke's healthcare system. @DrRichiMD Dr. Turner is an education and administration fellow at Baylor College of Medicine. anisha.turner@bcm.edu @DestinedDoc

Read more! • Excessive use of force by police: a survey of academic emergency physicians • Emergency department documentation of alleged excessive use of force • Disparities in Care: The Role of Race on the Utilization of Physical Restraints in the Emergency Setting

About ADIEM The Academy for Diversity & Inclusion in Emergency Medicine (ADIEM) works towards the realization of our common goals of diversifying the physician workforce at all levels, eliminating disparities in health care and outcomes, and insuring that all emergency physicians are delivering culturally competent care. Joining ADIEM is free! Just log into your member profile. Click “My Account” in the upper right navigation bar. Click the “Update (+/-) Academies and Interest Groups” button on the left side. Select the box next to the academy you wish to join. Click “save.”

SGEM: DID YOU KNOW? Presentation of Spontaneous Coronary Artery Dissection in the Emergency Department By Alexis Johnson MD and Neha Raukar MD, MS Acute coronary syndrome (ACS) has been predominantly recognized in men, likely due to the exclusion of women in the earliest research studies. Spontaneous coronary artery dissection (SCAD) is one form of ACS, however, that more often presents in women and is often overlooked on the chest pain differential in the emergency department. Defined as a non-iatrogenic, atraumatic dissection not associated with atherosclerosis, SCAD is emerging as a common cause of ACS in young women. Though initially thought to be rare, improvements in diagnostic technology in concert with an increased awareness has revealed that SCAD is far more common than originally suspected. SCAD predominately occurs in women age 45-53 with few atherosclerotic risk factors, has been associated with arteriopathies (particularly fibromuscular dysplasia) and connective tissue disease, and is the most common cause of pregnancy-related ACS. (Hayes, et al., Tweet, et al.) Although we often hear that women with ACS tend to present with “atypical” symptoms, numerous studies indicate women present just as often with typical ACS symptoms. (Mehta, et al.) The clinical presentation of SCAD is no exception. When symptomatic, patients with SCAD most often present like classic ACS. (Lindor, et al.) Unfortunately, their EKGs are often normal as may be their initial troponin, providing false reassurance in what is generally deemed a low-risk population. (Lindor, et al.) The key to diagnosis is a high clinical suspicion, as common risk stratification tools (for example the HEART score) rely heavily on atherosclerotic risk factors less frequently present in patients with SCAD and can provide false reassurance. Both serial enzymes and EKG should be obtained and, if SCAD is suspected, coronary angiography should be performed. Angiography remains the cornerstone of diagnosis even though it presents a risk of iatrogenic coronary dissection (particularly in the SCAD population) and is limited in visualization of the arterial wall. (Tweet, et al.) It is important to differentiate early between atherosclerotic ACS and SCAD, as treatment differs

between the two. In atherosclerotic ACS, expedient invasive revascularization is standard; however, due to the lack of success shown and high risk associated with percutaneous coronary intervention, observation is currently preferred in SCAD patients. The dissection will extend in fewer than 10% of patients in the first week post-SCAD event, thus observation is recommended. Optimal medical management is complicated as data is limited. In general, beta blockers and angiotensinconverting enzyme inhibitors or angiotensin receptor blockers are recommended, particularly in those with left ventricular dysfunction. Patients are often started on low-dose aspirin, as aggressive antiplatelet and anticoagulation therapy, as well as statin therapy, are not standard treatment unless otherwise indicated. Of note, up to half of patients experience chest pain after SCAD, the differential of which is consistent with that of atherosclerotic ACS, though dissection recurrence or extension should always be considered. (Tweet, et al.) SCAD is a unique cause of chest pain in an otherwise low-risk population. As women with ACS have historically been more likely to present later, are less likely to be admitted for cardiac ischemia, and are less likely to receive guideline-based care, vigilance and high clinical suspicion is vital for appropriate diagnosis and treatment. (Blomkalns, et al.)

SGEM "Did You Know?" is a recurring SAEM Pulse submission designed to represent concise facts that demonstrate how patient sex and gender effect emergency care. We welcome submissions. Please send contributions to the coeditors Lauren Walter and Alyson J. McGregor at sgem@lifespan.org.

ED ADMINISTRATION & CLINICAL OPERATIONS

Interfacility Load Leveling ED Admissions as a Strategic Solution to ED Boarding

SAEM PULSE | MARCH-APRIL 2021

By Hisham Valiuddin, DO; Paul Chen, MD, and Keith C. Hemmert, MD on behalf of the SAEM ED Administration and Clinical Operations Committee

As the demand for health care fluctuates with factors such as weekday variation and seasonality, emergency departments around the country routinely find themselves facing a debilitating issue: boarding. Every tertiary academic medical center is attempting to restructure, rethink, and restrategize their patient flow to combat this growing and debilitating challenge. Traditionally, after a patient is evaluated and treated in the emergency department (ED), a disposition decision is made to either admit or discharge the patient. If the patient needs to be admitted, an inpatient bed is requested, and a bed,

if available, is then assigned by the bed coordinator. Herein lies the problem: What happens when a bed is not available because inpatient capacity is already at maximum? The patient then “boards” in the ED. In other words, an admitted inpatient occupies an ED bed. A subsequent chain of events then occurs: ED capacity to continue caring for newly arriving patients is reduced, patient wait times go up, waiting room census increases, ambulances and incoming transfer patients requiring tertiary care are redirected to other hospitals, provider wellness plummets, and most importantly, patient safety and outcomes suffer. (Singer, et al.)

Over the past 15 years, many academic medical centers have expanded and consolidated, acquiring high functioning community hospitals to make integrated health systems. (Deloitte.com) This consolidation has enabled a new strategy to mitigate boarding: interfacility transfer of patients between affiliated hospitals at the point of admission. Specifically, when a patient needs to be admitted, rather than assign a bed in a hospital’s own inpatient ward — or, when no beds are available, board the patient in the ED — the patient is assigned a bed at an affiliated hospital. This strategic initiative is colloquially referred to as

“A reduction in boarding times consequently improves patient flow through the ED and leads to decreased ED waiting room times, which in turn leads to decreases in morbidity and mortality.” “load leveling,” for its mechanism of taking the “load” of patient admissions at one hospital and “leveling” that need across multiple hospitals within the health system, all owned by the same parent organization. Although on the surface a subtle innovation in the traditional hospital patient flow model, it is a change that has a significant impact on a health system across many levels of the organization, from clinicians and patients to the hospital board of directors. This mechanism can be used as a reactionary “safety valve” of decompression during times of extreme strain, or proactively to help prevent or reduce those times of extreme strain. Successful implementation of this admission load leveling strategy requires alignment of stakeholders at both hospitals, including leadership from hospital management executives, emergency departments, hospitalists, intensive care units, consultants, bed coordinators, and emergency medical systems (EMS). Protocols must be predetermined to ensure safe transfers between hospitals and to avoid situations such as transferring a patient to a hospital that has no bed availability or repeating workup and therapies. (EMTALA) Legally, patient consent must be obtained before such a transfer. (NHTSA) Considerations should be made to ensure that patients are not billed for such transportation service. One way to accomplish this is to have the health system, or the transferring hospital, absorb the cost of the transfer. The consolidation in academic health systems in the past 15 years has largely led to community hospitals transferring higher acuity patients to the tertiary center — a one-way flow into the quaternary academic hospital, which further strains inpatient capacity and exacerbates ED boarding. In this model, the tertiary hospital ED transfers patients requiring admission to the sister community hospital, so long as the community hospital has inpatient capacity and resources to accept the transfer. Identifying admitted patients

who don’t require tertiary care but require secondary care that can be provided at the community hospital is an important feature of these transfers. Transferring these secondary care patients creates additional capacity at the academic medical center for patients requiring tertiary care. This outflow leverages the varied resources of the health system not only by load leveling overall capacity, but also by placing patients in a hospital setting that matches their health care needs. This alternate route of outflow for patients requiring admission reduces the number of patients in the ED who are boarding and reduces the queue for inpatient beds at the facility already at maximum capacity. A reduction in boarding times consequently improves patient flow through the ED and leads to decreased ED waiting room times, which in turn leads to decreases in morbidity and mortality. (Singer, et al.) Reducing crowding in the ED also increases physician’s morale (Rondeau, et al.) and department productivity. (Pines, et al.) Load leveling admissions within a health system even has a significant financial upside for the collaborating hospitals by increasing revenues at the underfilled community hospitals, while preventing the tertiary ED from having to shut its doors by going on EMS diversion or declining transfer of patients requiring tertiary care. By not refusing patient ambulances, health systems can build equity and nurture relationships of reliability and trust with the local communities they serve, proving the ED will be able to deliver emergency care whenever the community needs it most. When a patient requires emergency care, they often have limited access to information such as ED volume or hospital capacity. In a critical situation, patients go to the nearest ED or are brought to the nearest ED by EMS. The patient is unaware of the wait time at their destination ED, which in times of strain can balloon to upwards of five hours. Once the patient is evaluated

and treated, if they require admission, lack of inpatient hospital capacity may force them to board in the ED, in some cases greater than 24 hours. Boarding essentially gridlocks patient flow much like a traffic jam on a highway, reducing the lanes open for traffic to pass through. Load leveling leverages a health system’s network of hospitals to create more lanes for patient care. Load leveling is a strategic initiative that, when implemented judiciously, has the potential to offer numerous advantages to a health system, its constituent hospitals, and its patients. Streamlined and safe interfacility transfer protocols can serve as sustainable solutions for difficult times when inpatient capacity is saturated. Load leveling admissions represents an innovative way to leverage the resources of a health system to improve patient flow, patient safety, provider wellness, and quality of care.

ABOUT THE AUTHORS Dr. Valiuddin is an emergency physician, Hospital of the University of Pennsylvania; Perelman School of Medicine at the University of Pennsylvania, Philadelphia. Dr. Chen is director of clinical operations in the department of emergency medicine at Brigham and Women’s Hospital; Harvard Medical School, Harvard University, Boston. r. Hemmert is an assistant D professor, medical director, and director of operations in the department of emergency medicine at the Hospital of the University of Pennsylvania where he also serves as the associate director, Fellowship in EM Administration and Leadership.

ETHICS IN ACTION

COVID-19 Disclosure vs Patient Confidentiality: Wading Into Uncharted Ethical Waters By Gerald Maloney, DO SAEM PULSE | MARCH-APRIL 2021

The Case

You see a 57-year-old female patient in the emergency department (ED) with fever, cough, and myalgias. She tests positive for COVID-19. She is clinically stable for discharge, but you discuss quarantine. She relates that she works as an RN at an extended care facility and that she has to go to work because she used up her sick time earlier in the year caring for her family and has no more available. She reveals that while working during two previous days her employer was unaware she was exhibiting symptoms. She expresses her wishes that information regarding her COVID-19 diagnosis be withheld from her employer. By continuing to work she is likely to expose her elderly and chronically ill patients to COVID-19. Given this, you wonder if you can/should tell her employer regardless of her wishes.

“The confidentiality of the physician-patient relationship is one of the most sacred tenets in medicine.” Considerations

The confidentiality of the physician-patient relationship is one of the most sacred tenets in medicine. The ability to gain the patient’s confidence with the knowledge that what the patient

“The disclosure of what would otherwise be private health information when there is a compelling risk to the public follows the utilitarianism principle that often guides public health decisions, where the benefit is not focused on the level of the individual patient but rather at the level of society as a whole.” discloses will remain private is necessary if the patient is going to fully disclose potentially crucial information to the physician. This privacy is codified in both professional ethics, such as the AMA Code of Ethics, and law, with HIPAA being the best known of these privacy laws. Because of this, any breaches of confidentiality are treated as serious issues that can have both professional and legal implications for the physician who chooses to violate them. Confidentiality also is enshrined in the basic ethical tenets of autonomy, beneficence, and non-maleficence. Autonomy, the ability of the patient to make choices about their care, including who should or shouldn’t get their information (within the realms of permissible disclosures, such as for insurance), is arguably the most central ethical principal. Beneficence, the concept that we should always choose what is in the best interest of the patient (in accordance with their wishes), and non-maleficence, that we should not do things that can harm our patient, also factor into the release of information. Again, confidentiality is front and center as an ethical concept in the physicianpatient relationship. That said, there are times when the confidentiality principle can be overridden. Legal requirements may force us to disclose information, even against the patient’s wishes or even if there is potential negative impact to the patient. Examples include reporting gunshot or stab wounds, obtaining blood alcohol or urine drug specimens in states where such collection can be legally mandated in certain instances, or reporting when there is a compelling public health issue. An example of the latter is an airline pilot who has had a seizure, where allowing him or her to

go to work could jeopardize the lives of hundreds of passengers. This last is an example of where public health ethics conflict with the ethical tenets that we use when considering the individual physician-patient relationship. The disclosure of what would otherwise be private health information when there is a compelling risk to the public follows the utilitarianism principle that often guides public health decisions, where the benefit is not focused on the level of the individual patient but rather at the level of society as a whole. Thus, decisions that may not be the wishes or to the benefit of the individual but may instead be for the benefit of the greater society can still be ethical. The decision specifically regarding release of information about infectious disease is a complicated one. The most well-known recent discussions on this topic have been regarding HIV. A common ethical dilemma was whether to disclose to a known third party that they could be at risk, even if the patient did not wish that the information be shared. The typical example is a patient who tests HIV positive but does not want his spouse to know his test results. In this case, the third party can be easily identified. The duty to report to a threatened third party has been established in other cases, but not in HIV cases. COVID-19 is too new to have any established case law. However, the threat that an infected person might expose individuals to COVID-19 who are at high risk of severe complications or death from the disease, as well as the fact that the period of contagiousness (unlike HIV) is generally limited to days, makes standards used for HIV not directly applicable. There is now effective treatment for HIV while treatments for COVID-19 are less effective. Also,

consider the ease of transmission of COVID-19 compared to HIV, which makes spread to a large number of persons more likely. Compounding these decisions is where to draw the line on disclosure. Any patient, even those not working in a high-risk environment, can go out into public unmasked and spread the disease to unknown others.

The Conclusion

In our case, no current explicit legal guidance exists, making it an issue that must be decided based on local opinion and guidance. There will not likely be universal agreement on whether the patient should lose her right to confidentiality in this setting. It is this author’s belief that the patient’s failure to agree to quarantine while ill places a vulnerable population at risk and therefore ethically overrides the patient’s desire for confidentiality. Patients may accept risks that are personally detrimental, but in this case, by going to work while ill and not disclosing it, this patient is putting the health of a high-risk population in jeopardy without its consent. In this respect, it is similar to the airline pilot who had a seizure yet still wants to fly. As the pandemic progresses and more of these cases arise, better legal guidance will be established on this subject. Until such time, each case should be managed by considering the full ethical and legal implications.

ABOUT THE AUTHORS Gerald Maloney, DO, associate professor of emergency medicine, Case Western Reserve University and associate medical director, Louis Stokes Cleveland VA Medical Center.

GLOBAL EMERGENCY MEDICINE

COVID-19 Outbreaks Within Immigrant Detention Facilities SAEM PULSE | MARCH-APRIL 2021

By Erica Concors, MD, MPH; Miya Smith, MD; and William Weber, MD, MPH

Changes in U.S. immigration enforcement over the past few years have multiplied the number of detained immigrants, leading to crowded facilities that have faced large scale outbreaks of COVID-19. The current crisis of COVID-19 outbreaks in immigrant detention centers provides emergency physicians with new opportunities to support the global community from home.

The Growth of Immigrant Detention in the U.S.

The United States contains the largest immigration detention system

in the world. Under the oversight of U.S. Immigration and Customs Enforcement (ICE), Enforcement and Removal Operations oversees the apprehension and detainment of undocumented individuals within U.S. borders. These individuals are housed in one of approximately 200 facilities managed by ICE in coordination with private contractors, state, and local governments. ICE detention has experienced an exponential expansion in recent years. Since 2017, ICE has opened over 40 new detention centers and the average daily population of detained immigrants increased from

approximately 7,000 in 1994, to 19,000 in 2001, to over 50,000 in 2019.

Concerns About Medical Care in Detention Prior to the Pandemic

In light of the growing number of individuals in ICE custody, there has been increasing concern about the organization's ability to maintain mandated standards of care. The National Detention Standards (NDS) is a set of mandates that outline basic regulations for detention facilities, including the delivery of medical care to detained individuals. These standards include such provisions as medical

Photo courtesy of U.S. Customs and Border Control, U.S. Government

“Despite an overall decrease in detention center populations, detained individuals continue to face a significant risk of contracting COVID-19.” screening exams on arrival and access to interpreter services. The ICE Health Service Corps (IHSC) oversees the health care of detained individuals and reported more than 300 outbreaks of infectious disease at 51 facilities between June 2018 and June 2019. A 2020 investigative report published by the U.S. House of Representatives Committee on Homeland Security entitled Ice Detention Facilities: Failing to Meet Basic Standards of Care, found that “ICE contracts with detention facilities that are poorly equipped to meet the agency’s own detention standards.”

The COVID-19 Response and Outbreaks Within Detention Facilities

The COVID-19 pandemic has created a further strain on the U.S. detention system. Early in the pandemic, organizations like the Centers for Disease Control and Prevention (CDC) produced pandemic response guidelines including hygiene, social distancing, and testing protocols to help mitigate risks of the virus. ICE also released the Enforcement and Removal Operations COVID-19 Pandemic Response Requirements

(ERO PRR), which provided guidelines for all ICE detention facilities to manage COVID-19. ERO PRR mandated that detained immigrants have adequate access to masks, soap, and hand sanitizer, particularly when confirmed COVID-19 positive. However, a Federal Office of the Inspector General report found that only 31% of facilities reported sufficient hand sanitizer supplies and 89% had enough masks for COVID-19 suspected or positive detained continued on Page 30

Photo courtesy of U.S. Customs and Border Control, U.S. Government

GLOBAL EM

SAEM PULSE | MARCH-APRIL 2021

continued from Page 29

immigrants. The same report also found that only 12-15% of facilities reported the ability to isolate detained immigrants with confirmed cases of COVID-19 and 29-34% of facilities lacked negative pressure rooms. The discrepancies between the policies of the CDC and ICE and conditions at detention facilities have likely contributed to outbreaks at many facilities nationwide. Despite an overall decrease in detention center populations, detained individuals continue to face a significant risk of contracting COVID-19. Overall, approximately 15,000 individuals remain in detention as of January 2021 and more than 9,000 detained individuals

“Studies have noted COVID-19 positivity rates in detention facilities averaging over 13 times greater than that of the general U.S. population.” and staff have been confirmed COVID-19 positive. Studies have noted COVID-19 positivity rates in detention facilities averaging over 13 times greater than that of the general U.S. population.

How Emergency Physicians Can Get Involved

Emergency physicians play a key role in supporting the health of detained

immigrants on both systemic and individual levels by providing safe and holistic care in the emergency department, writing medical declarations, and advocating for immigrant rights. Regardless of personal perspectives on immigration reform, physicians should care about the health of all people and advocate for appropriate care.

“Emergency physicians play a key role in supporting the health of detained immigrants on both systemic and individual levels by providing safe and holistic care in the emergency department, writing medical declarations, and advocating for immigrant rights.” Caring for Undocumented or Detained Individuals in the ED

Emergency physicians often care for patients who are undocumented and can take steps to protect their rights and ensure that they receive proper medical care. Emergency departments are “sensitive locations” where ICE or other immigration officials are generally not allowed to conduct immigration enforcement activities. If officials request access to a patient in the ED, they should be directed to the hospital legal team to ensure that they have the correct warrants and documentation prior to proceeding. Emergency physicians typically care for immigrants whose health deteriorates while in a detention center. Physicians who witness the effects of poor treatment firsthand should alert the warden at the detention facility or the state medical board about unsafe conditions. They should also document any recommended medications, treatments, or specialty follow-up appointments to keep facilities accountable for the ongoing care of these patients.

Supporting Detained Individuals Through Medical Declarations

Physicians can support detained individuals by writing medical declarations in pursuit of adequate treatment. Medical declarations are legal documents that discuss medical conditions or care of a patient. Declarations can detail how facilities are failing to provide mandated care to immigrants, putting them at risk. For instance, a medical declaration detailing the COVID-19 risks to a 76-yearold, diabetic patient at a facility with

mask shortages might persuade a judge that the patient would be safer staying at home with family until their court date rather than remaining in a detention facility. Similarly, declarations can outline concerning treatment, such as a patient with persistent tachycardia and chest pain who has not undergone any cardiac evaluation. Medical declarations can be powerful tools to achieve meaningful change for individuals.

Political Advocacy for Quality Medical Care in Detention

Emergency physicians can advocate for systemic changes through political action to support adequate medical care for immigrants in detention. Highprofile legal cases about outbreaks of COVID-19 and poor medical treatment in detention have recently emerged, spurring calls to action. Emergency physicians are familiar with standards of care and can use their experience to advocate for quality medical treatment such as abiding by CDC infectioncontrol guidelines, obtaining informed consent for procedures, and providing interpreter services for those who have difficulty communicating in English. Politicians generally respect the training and experience of physicians and calls or emails can lead to policy change.

Conclusion

The increased number of individuals detained by ICE combined with an inability to provide adequate protective measures have contributed to the spread of thousands of cases of COVID-19 in detention facilities and numerous deaths. Emergency physicians can support detained immigrants at many levels. In

the emergency department, they can protect the rights of their patients and flag examples concerning care at outside facilities. For individuals who are detained, emergency physicians can write medical declarations highlighting issues in care. At a systems-level, emergency physicians can advocate for changes to the detention system to ensure that detained individuals are provided basic, mandated medical care.

ABOUT THE AUTHORS Dr. Concors is an emergency medicine resident at the University of Chicago. They are interested in LGBTQIA+ health, social emergency medicine, and fighting for social justice in health care. Dr. Smith is an emergency medicine resident at the University of Chicago with an interest in social emergency medicine and forensic medicine. She currently serves on the Illinois State Medical Society, the ACEP Forensic Medicine Section and as an EMRA Health Policy Academy Fellow. Dr. Weber is an international emergency medicine fellow at the University of Chicago focusing on immigrant/refugee health. He has worked in Zambia, Ecuador, and South Africa, and serves on the Public Health and Injury Prevention Committee of ACEP.

About GEMA The Global Emergency Medicine Academy (GEMA) focuses on improvement of the worldwide delivery of emergency medical care. Joining GEMA is free! Just log in to your member profile. Click “My Account” in the upper right navigation bar. Click the “Update (+/-) Academies and Interest Groups” button on the left side. Select the box next to the academy you wish to join. Click “save.”

MEDICAL EDUCATION

Medical Educational Scholarship and MedEdPORTAL SAEM PULSE | MARCH-APRIL 2021

By Suzi Bentley, MD, MPH and Dan Mayer, MD on behalf of the SAEM Education Committee

If you spend a lot of time teaching and developing educational activities for medical students or resident learners, you want and deserve recognition for your scholarly works. In the past, ideal faculty possessed the “triple threat” of excellence in clinical practice, research, and teaching. Few faculty ever achieved this and teaching efforts have historically been undervalued. Teaching expected as part of “academic citizenship,” was necessary but insufficient for promotion. Excellent researchers and clinicians were given a pass on being good teachers. Academic promotion and tenure came from the amount

“MedEdPORTAL is a repository for highquality educational resources supporting training health professionals, relaying new knowledge, influencing behavior, and inspiring learners.” of grants and number and quality of publications, with teachers falling behind in recognition.

In the 1980s the Association of American Medical Colleges (AAMC) recognized the need to improve

“Teaching as the focus of educational publishing should be intentional, driven by clear and measurable objectives and centered on meeting the needs of the learner.” teaching. Yearly meetings newly emphasized inclusion of clinician educators. Medical schools hired educational specialists to improve curricular content and visionary faculty created new types of educational experiences. In 1990, Ernest Boyer, president of the Carnegie Foundation defined four domains of educational scholarship or “academic endeavor”: 1) discovery (traditional research), 2) integration (between specialties), 3) application (knowledge translation) and 4) teaching (educational scholarship). Educational scholarship was defined as creating new knowledge about teaching and learning in the presence of learners. Teaching as the focus of educational publishing should be intentional, driven by clear and measurable objectives and centered on meeting the needs of the learner. Scholarly teaching worthy of publication and dissemination adds evidence about the content and process of an educational session or curriculum including the perspective of the learner to assess its usefulness. Proposed by the Educational Scholarship Working Group of the Group on Educational Affairs of the AAMC, MedEdPORTAL became a reality in 2005, led by then editor-in-chief C. Candler, MD, EdD and editorial director R. Reynolds. The current editor-inchief, G. Huang, MD is supported by a large and professional editorial staff. MedEdPORTAL filled the need for a peer reviewed publication highlighting quality educational scholarship focused on the actual process of teaching and became indexed in PubMed in 2018. The process of submission to MedEdPORTAL involves strict peer review and editorial oversight. MedEdPORTAL is a journal that publishes educational activities, which are submitted as “stand alone” exercises and can be individual lectures, small group sessions, simulation or standardized patient cases, curriculum designs and assessment tools. The

submission should have enough information so that a faculty member at any medical institution can reproduce the material/educational activity. The Educational Summary Report (ESR) is a manuscript that details the nature of the topic being taught, educational objectives, target learners, faculty information, and evaluation information. The entire submission should follow Glassick’s criteria for educational scholarship inclusive of clear goals, adequate preparation, appropriate methods, significant results, effective presentation and reflective critique. Educational objectives should be specific, measurable, achievable, relevant, and timebound (“SMART”). The evaluation should show increased acquisition of knowledge or skills and assessment of the usefulness of the submission. The ESR is formatted with an abstract, introduction (background), methods, results, discussion, and references. Appendices contain the actual materials used in the teaching process. Currently there are five emergency medicine associate editors: J.P. Sanchez (diversity, inclusion and health equity), M. Cassara and D. Mayer (emergency medicine), R. Burns (pediatrics), and J. Kutzin (simulation). These editors are available to help determine whether your educational project is suitable for submission to MedEdPORTAL and can also help with the content. The editorial staff are available to assist you in preparing the correct formatting and content of your presentation. MedEdPORTAL is freely searchable and submissions are designed to be executed without additional materials. This can support busy faculty to become better educators through using and creating shared curricula that are proven effective and available for other users. MedEdPORTAL is a repository for highquality educational resources supporting training health professionals, relaying new knowledge, influencing behavior, and inspiring learners.

ABOUT THE AUTHORS Dr. Bentley is an emergency medicine attending physician and the medical director of simulation at the Simulation Center at NYC Health+Hospitals/Elmhurst. She is an associate professor of emergency medicine and medical education at the Icahn School of Medicine at Mount Sinai. Dr. Mayer is retired as a rofessor of emergency medicine from Albany Medical College where for 27 years he taught evidence-based medicine and emergency medicine to medical students, physician assistant students, residents and faculty. He is an associate editor of MedEdPORTAL (emergency medicine).

Read more! • Scholarship Reconsidered: Priorities of the Professoriate • The Scholarship of Engagement • Scholarship Assessed: Evaluation of the Professoriate • Scholarship in Teaching: An Imperative for the 21st Century • Recognizing and Rewarding Clinical Scholarship 33

SAEM PULSE | MARCH-APRIL 2021

THE VIRTUAL EDUCATOR

Interview with a Technological Disruptor: Introducing Edutainment to the Medical School Classroom By Alexis del Vecchio, MD on behalf of the SAEM Virtual Presence Committee Q: Tell us about your path to emergency medicine. A: After attending the University of Calgary for my bachelor of health sciences and doctor of medicine degrees, I went to the University of Alberta for family medicine. I returned to Calgary for additional training in emergency medicine. I work in rural emergency departments and urgent care. I teach emergency medicine and foundational clinical skills to medical students as the “Intro to Clinical Practice” course chair and clinical assistant professor at the University of Calgary.

Anthony Seto, MD Anthony Seto, MD is an emergency medicine physician and course chair at the University of Calgary Medical School. He and I recently spoke for over two hours on Zoom, here are a few tidbits from our engaging conversation!

Q: Did you always know you wanted to be a doctor? A: I think it was always on the differential. I wanted to be an actor in grade one, and a movie director in junior high. I considered becoming a high school teacher. Now I get to combine these with my role in medical education. I like to think of myself as an edutainer! I grew up

teaching first aid and lifesaving courses and loved running CPR and rescue scenarios. All this made me interested in doctoring. I doctor in the evening and edutain during the day.

Q: Do you think “edutainment” is the future of medical education? If we look at the most successful educational products, they combine an element of entertainment with striking visuals: SketchyMedicine, Khan Academy, podcasts, etc. A: I love edutainment. I think it’s the future of education. When I go to conferences, not only do I learn about medicine, I also from other educators how they “edutain.” I feel like Essentials of Emergency Medicine does this well. I learn emergency medicine and delivery strategies! I believe creating an engaging lecture is like producing a show.

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VIRTUAL EDUCATOR

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SAEM PULSE | MARCH-APRIL 2021

Q: How did you start exploring innovative teaching?

A: I was inspired by my predecessor, Dr. David Keegan, a family doctor who also trained in emergency medicine — the previous course chair. He played music during lectures and used videos. My other inspiration was from the aquatics industry (I used to work as a lifeguard) where teaching young adults and trying to simplify medical topics required creative thinking to keep them engaged. I have been trying to gamify all curricula I have created.

Q: I’ve gotten to experience some of your approaches to teaching; they are fun and engaging! Can you provide us examples? A: I like making course trailers to engage students and our teachers. Here is musical trailer: Intro to Clinical Practice (ICP) “The Greatest Show” and here is a dramatic one: Intro to Clinical Practice End Preclerkship. This was a lecture

“We have to make sure our approaches are aligned with the learning objectives. Choose delivery methods that effectively teach what you want the students to learn.” we did as a gameshow: Approach to Fluids Live and this was a course we conducted with a “secret agent theme”: Electronic Clinical Resources. We conducted these lectures live, but because of COVID-19, have made them into podcasts. The "Intro to Clinical Practice Teaching Opportunities" on page 35 shows teaching opportunities for our course coming up and gives you an idea of the funky sessions we have. I even submitted something for the ACEP conference TikDoc contest! (Thanks for including me, American friends!)

Q: I note that you engage medical learners in your productions too?

A: I try to! Recently, our course had a “finale lecture” that included residents and medical students. I like having medical learners as “cameos.” I think they like hearing from someone closer to their training. Having nurses and paramedics join us in teaching in an interprofessional format has been very well received by facilitators and medical students. Here’s an online simulation demonstration video with staff, a resident, medical student, and nurse: Intro to Clinical Practice. Thanks to Dr. Sarah Foohey from Toronto for making this fantastic online platform, the Virtual Resus Room, for us to adapt!

“It’s not all about technology, but the connections and the people you meet, and different ways of doing things, and then aligning those to your own learning objectives and making something new.” Q: What is the barrier to entry for instructors interested in engaging with innovative teaching? You are obviously facile with utilizing advanced software. What about the rest of us who don’t have a production background? A: If you’re thinking about using videos as a teaching method, you can use Zoom and your cell phone. That’s what I use. No fancy cameras! You start a Zoom meeting, share your screen, and then record yourself. I edit my videos with Final Cut Pro but editing software like iMovie works too.

now we’ve adapted your curriculum on acting-based communication skills for my medical students. My techniques have always been around gamification, just because I like games. I like allowing people to be more self-directed in their learning, because they’re actively participating in the game. And they’re also more able to collaborate. When students are on the same team and teach each other, I feel like they learn better.

Innovation doesn’t have to be technological, either. It just requires different angles outside the norm. For example, I had students write “orders” on sticky notes and then “post them” on the manikin to deliver that order. This forces students to commit to decisions. I have also turned a simulation theatre into an escape room with papers, props, locks, and boxes for teamwork training.

me. I realized that any innovation may face pushback. Over time, the community became more supportive of these innovations. What helped was doing a thorough needs assessment and background literature search and presenting the innovative pitches in an organized fashion. I have had an opportunity to show evidence in support of this work. Each of our course’s workshops is grounded in literature and evidence. We review post-course evaluations to improve our curriculum and delivery methods. We’ve been able to share our work locally, nationally, and internationally, and it’s been very well received.

Q: Where do you see medical education heading and yourself ten years from now? A: In terms of medical education, I think we are starting to move away from lectures and toward more selfdirected and interactive, team-based learning. I think the COVID-19 pandemic accelerated this evolution, where we’re moving more towards technologicalbased activities such as on-demand podcasts.

We have to make sure our approaches are aligned with the learning objectives. Choose delivery methods that effectively teach what you want the students to learn.

Q: Any specific models or resources you can provide to teach differently?

Q: I imagine most students respond favorably to this approach, but are there some who just don’t?

A: I always go back to Kern’s Curriculum Development model. It starts off with general and targeted needs assessments. Ask the students, “What’s working now and what’s not working?” Then, decide on the objectives and how you’re going to deliver them. Implement the innovation, then seek feedback, and reflect on it. What got me started was attending as many medical education conferences and faculty development workshops as possible. It’s not all about technology, but the connections and the people you meet, and different ways of doing things, and then aligning those to your own learning objectives and making something new. That’s how I met you, Alexis. And

A: I think there’s always going to be varied opinions; however, observations of it happening are incredibly rare: out of a class of 160 on average, with response rates of 40 to around 100, you would only get one critical comment, maybe every other year. One example would be, “Oh, can you please not play music so loud? I have migraines.” Okay, fair enough. So the next year, I just turned down the volume, and that comment didn’t recur. I had someone mention from the medical school to be careful as some may think that our course is starting to look “frivolous.” This term haunted

For the next ten years, I hope to continue to disrupt and innovate and change people's perspectives of not always having to follow the norm. I plan to continue to create EPIC curriculum— Engaging, Practical, Innovative, Clear— which is the teaching philosophy of our course.

ABOUT THE AUTHORS Dr. del Vecchio is an emergency medicine resident physician at Mayo Clinic, with a passion for education innovation. A professional actor, he created an acting-based course to improve the communication and interpersonal skills of healthcare professionals. He can be reached on Twitter @TheActorDoctor and at delvecchio.alexis@mayo.edu.

WELLNESS & RESILIENCE

Burnout, Moral Injury, Vicarious Trauma, PTSD and the COVID-19 Pandemic: A Year in Review

SAEM PULSE | MARCH-APRIL 2021

By Al’ai Alvarez, MD; Nicole Battaglioli, MD; and Nathalie Martinek, PhD on behalf of the SAEM Wellness Committee

By the time you read this, it has been at least a full year since the pandemic began. Some of you may have even battled the virus yourself. While the arrival of COVID-19 vaccinations offers a glimmer of hope, chances are you are still in the thick of overwhelmed and overcrowded emergency departments, back-to-back Zoom meetings, workhome conflicts, and feelings of social isolation. We end up internalizing this trauma, and these challenges affect us in more ways than we can fully comprehend right now. We are suffering from burnout and moral injury. Labeling the phenomenon with precision helps with healing, yet available literature interchangeably uses the concepts of burnout, moral distress, vicarious trauma, and PTSD.

Even before the pandemic, the WHO considered burnout in the occupational context as a “syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.” Three dimensions characterize burnout: “feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and reduced professional efficacy,” garnering its own ICD-11 code. One study showed half of the health care workers surveyed from 60 countries reported burnout symptoms six months into the pandemic. The pandemic has exposed multiple disparities and barriers to care in our health care systems, exposing the institution’s role in creating occupational

hazards when trying to ensure patient and physician safety. We are also finally acknowledging that burnout is not due to personal deficiency or inadequate coping skills when faced with constant occupational stressors. Our burnout is not due to a lack of resilience, but is a symptom of the systems-based trauma of physicians. Contributing factors to systems-based trauma include the electronic health record’s inefficiencies, understaffing, patient boarding, unrealistic metrics, and opaque reimbursement schemes. As emergency physicians, we know burnout. We’ve experienced our own burnout and have witnessed it manifest in our colleagues. We need to recognize the limitations of current burnout

“Our burnout is not due to a lack of resilience, but is a symptom of the systems-based trauma of physicians.” mitigation approaches and explore our symptoms to pinpoint different sources of trauma and injury. While enduring vicarious trauma and moral injury is not a new phenomenon for those who work in health care, the COVID-19 pandemic has added additional layers of stress and emotional tax that worsen the assault on our sense of personal and community safety. Trauma can result from a betrayal of trust that threatens our safety and life in general. The betrayal of trust can result from another person’s actions (e.g., racism, harassment, bullying), a life event (e.g., diagnosis, litigation, or death of a loved one), or environmental circumstances (e.g., the pandemic, natural disaster, war, or occupational hazards). The existing sense of safety about the world is damaged due to a traumatic experience, which then impacts self-trust and trust in others and the world around us to keep us safe. Moral injury refers to a type of trauma caused by the betrayal of self through the violation of one’s moral values so as to uphold the system’s expectations, and results in the harm of someone, such as our patients or colleagues in a more vulnerable position. Having to decide on caring for COVID-19 patients in distress while putting ourselves in direct harm’s way (lack of PPE, extra shifts, or shortened or canceled shifts), can all lead to moral injury. However, moral injury is challenging to understand because we often attribute the blame to the system. In reality, our own actions directly cause or threaten harm either because of our inability to stand up to the system or because we feel compelled to follow. Carrying out the action that harms someone when we’re in a role to provide help goes against our oath and mission as physicians. This distinction is critical in understanding causes of moral injury and the healing process that involves acknowledging and reconciling the dual role as enactor of harm and the harmed. Vicarious trauma, referred to in the literature as second-victim syndrome or second-trauma syndrome, is a different entity. An argument against second-

victim syndrome is that it uses the word “victim,” which is disempowering while displacing the traumatic event’s primary victims. Regardless, this phenomenon refers to the transmission of traumatic stress by bearing witness to experiences of traumatic events and internalization of victims’ stories. Witnessing patient after patient suffering the effects of the COVID-19 virus is traumatizing, although not foreign in our line of work. Moreover, we take on secondary trauma when we lose colleagues and loved ones to COVID-19, watch the news, read about the increasing COVID-19 death toll, and scroll through our social media. Over time, this secondary trauma can result in cumulative adverse effects and exacerbate an individual’s unresolved personal trauma or internalized story. Post-Traumatic Stress Disorder (PTSD) refers to a “severe, disabling disorder following exposure to a traumatic event,” characterized by “intrusive thoughts, nightmares, and flashbacks of past traumatic events, avoidance of reminders of trauma, hypervigilance, and sleep disturbance.” Whether or not you have taken the time to reflect upon these events in your own experience, according to the book, The Body Keeps The Score, “neuroscience research shows that the only way we can change the way we feel is by becoming aware of our inner experience and learning to befriend what is going inside ourselves.” Moral injury and PTSD are outcomes of unresolved trauma. Each of these events takes its toll on our mental health, and we anticipate seeing the effects of this parallel pandemic for years to come. Healing takes time, commitment, and diverse support infrastructures to process and integrate trauma. Discerning what is in the realm of “my responsibility” (skills development, gaps in knowledge, fatigue) vs. systems-failure (interruptions, lack of resources, overcrowding) is paramount to understanding which therapeutic modality is appropriate. Mindfulness and selfcompassion effectively treat the former, while the latter requires organizational solutions. Moreover, offering selfcompassion to the latter can be further

traumatizing and victimizing, just as no amount of yoga or meditation can fix inefficiencies of practice. As we look towards ourselves, our fellow emergency physicians, and colleagues on the front lines, understanding these differences will help us better tend to our suffering. Professional mental health support is vital in understanding our experiences, yet seeking help continues to be associated with significant stigma. Perhaps a critical takeaway from the pandemic is that as academic emergency physicians, we must normalize self-care, including asking for help, and design and study efficacious structural interventions addressing institution-specific occupational hazards. We must strive to use precise language in our work to gain better knowledge on its impact on the physician workforce and explore effective ways of prevention and treatment. If you are having thoughts of suicide or self-harm, please call a friend or a loved one, or the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK).

ABOUT THE AUTHORS Dr. Alvarez is a clinical assistant professor of emergency medicine and an assistant residency program director at the Stanford Emergency Medicine Residency Program. @alvarezzzy Dr. Battaglioli is assistant professor of emergency medicine at Emory University. She is co-founder of the Academic Life in EM (ALiEM) Wellness Think Tank. @batt_doc Dr. Martinek is a well-being mentor, coach and educator for physicians and health care professionals. She is the cofounder Safe Space Health and Behaviour Health. @NatsforDocs

SAEM PULSE | MARCH-APRIL 2021

A Picture Is Worth a Thousand Words: Utilizing Smartphone Technology in the Evaluation of ENT Emergencies

By Seth Lotterman, MD Telemedicine is not a new tool and has been available and used by emergency physicians for some time. For example, many emergency physicians are familiar with the use of teleneurology during the evaluation of patients with neurologic emergencies. However, the COVID-19 pandemic has sped up the adoption of telemedicine in a variety of other settings. Improved infrastructure, such as the advent of broadband wireless and improvements in smartphone camera and video capabilities, along

with HIPAA compliant text messaging applications, have increased the potential capabilities of telemedicine. These innovations allow for transmission of clinically useful images to consultants who are not able to immediately evaluate an emergency department patient at the bedside. Many community emergency departments lack subspecialty coverage and the ability to transmit images with high enough quality to assist in real-time medical decisions can be extremely helpful and may help avoid unnecessary transfers. Recent studies using images obtained

with smartphones demonstrated that the image quality was sufficient to allow for remote attending otolaryngologists to assess nystagmus with the performance of the Dix-Hallpike maneuver to facilitate the diagnosis of benign positional peripheral vertigo (BPPV) and to assess for the presence of a retropharyngeal abscess. In one study, by Shah et al, a smartphone was used to record a patient’s eye movements during the performance of the Dix-Hallpike test and the video was later viewed by attending neuro-otologists, who were able to identify BPPV with 85% sensitivity

“Many community emergency departments lack subspecialty coverage and the ability to transmit images with high enough quality to assist in real-time medical decisions can be extremely helpful and may help avoid unnecessary transfers.” and 100% specificity. In the other study by Mallen et al. “Utility of Smartphone Telemedical Consultations for Peritonsillar Abscess Diagnosis and Triage” video recordings of patients with suspected peritonsillar abscesses were reviewed by attending otolaryngologists who were able to diagnose PTA with 83% accuracy and moderate agreement between the attending otolaryngologists. All but one of the videos was felt to be of high enough quality to make a diagnosis. This technology could be also used in the evaluation of a patient with airway obstruction by sending clips of fiberoptic laryngoscopy for otolaryngology review.

Invited commentary by Thal and Mehta regarding the retropharyngeal abscess article discussed that potential for improvement in patient care, decreasing wait times and reducing the use of unnecessary radiologic imaging and developing algorithms to manage otolaryngology conditions such as otitis externa, sialadenitis, and neck abscess. While there have been significant strides and growth in the implementation of telemedicine in the general medical community, the COVID-19 pandemic has accelerated the use of telemedicine in many facets of the medical community. The use of telemedicine has the potential

to decrease unnecessary transfers and facilitate timely outpatient follow-up. The author hopes that this will continue to be utilized and result in more efficient and improved patient care.

ABOUT THE AUTHORS Dr. Lotterman is assistant residency program director and assistant professor of emergency medicine at the University of Connecticut.

A View of Infinity

SAEM PULSE | MARCH-APRIL 2021

By Ray Fowler, MD

It’s a long time now, over 40 years in the emergency department, lingering over case after case, thinking and reflecting on the prolonging of life. Years ago, my attorney brother and I were at the bedside of our mother, struggling against the BiPAP that was supporting her breathing during the sepsis from peritonitis that was taking her away. She said, “Let me go!” and we sadly went to the desk — after we conferred with her and then together — and signed the DNR form that would lead to her being moved to a morphine drip at a hospice called “Tranquility.” The typical staff member there had spent 20 or more years as ICU nurses: Years spent helping people check back in. Now they were lovingly helping patients, like our mother, check out with love and grace. I have never witnessed more loving care by such gentle souls. At the end, the peace that passed all of our understanding that came

over our mother had no reference that I could describe. In one moment she was sleeping and breathing softly, and then the next moment she lay still, amid a vision she must have been having of an infinity that opened before her. Somebody had told me years before that the first dream you have of a loved one after they pass tells you how they are spending eternity. Not long after my Dad passed after a sudden heart attack in his 80s, I dreamed that we were all at a party, wearing formal wear, and my Dad, a little smaller in stature but so real in my dream, was the life of the party! I knew that he was doing just fine in the hereafter. After Mom died, I had to look inside with the passing years to find my own comfort with that “view of infinity”: The giving over of life to embrace a hereafter that, with those of faith, we aspire for a measure of confidence in our universal continuity that transcends our last breaths, our final heart beats, that is

measured in significant part by the love of those who remain behind, and is lodged in our minds as we approach the final adventure of life. He was a bit younger than me, lying there writhing with his back pain. A colon cancer survivor, he was now having a moribund, unrelenting lumbar agony that had worsened over the last few weeks. He said, “I hoped it would go away, but it didn’t.” His pallor, his tachycardia and diaphoresis, his drawn face all murmured to me that this had the chance of not being a diagnosis that either of us would want to know. And, indeed, on the CT scan his bones were riddled with metastases, his acute pain caused by the severe pathologic compression of his second lumbar vertebra. This was as bad a prognosis as it could possibly be, and I made arrangements to admit him for pain control and what care our wonderful cancer team could offer.

“In one moment she was sleeping and breathing softly, and then the next moment she lay still, amid a vision she must have been having of an infinity that opened before her.” I remembered a long time ago that somebody told me, in dealing with patients whose fates hang precariously, “Never destroy someone’s hope. Sometimes, that’s all they have.” So, I returned to my patient’s side, there in the late evening of the ED, surrounded by the ill and infirm of a large urban emergency center. His sweet nurse came with me, to stand opposite me at the bed. Taking his hand, I sat on the edge of the bed and asked if he was feeling better from the morphine. He said that he was, that he was a bit more comfortable. “I’m going to put you in the hospital,” I said, “and give you some medicine to make you feel better.” “What is it, Doc? What’s going on with me?” he asked. I said, “Well, I’m not sure, but I do see some areas in your back that concern

me...you may have cracked one of your vertebrae.” “Is it my cancer coming back?” he asked. I reflected for a moment, about what someone had told me about hope, and about life, and about not taking away someone’s will to live. “I’m not sure,” I said. “It might be, but we won’t know that for a bit.” Then, wanting to help him move to a place where he might feel some control, I said, “But, I have a job for you. We have to keep your pain under control, because feeling a lot of pain can weaken your strength.” And then, I said, “Your job is to monitor your pain and to let us know if you feel more uncomfortable. Then, you need to let us know, and we’ll bring some medicine for you. Can you do that?” He said that he would.

I sat there for another moment and held his hand. We both knew the score, and we just looked at each other for a while. I squeezed his hand a last time and rose from the bed to stand, still looking at his eyes. And, I swear to you, I could see in his eyes a view of infinity. Moving to the door, I headed to the hallway, to the long night in the emergency department that lay ahead.

ABOUT THE AUTHORS Dr. Fowler is a professor and chief, division of emergency medical services and the James M. Atkins M.D. Distinguished Professor of Emergency Medical Services at UT Southwestern.

Why It’s Important for My Patients to Know I’m a Doctor SAEM PULSE | MARCH-APRIL 2021

By Anita Chary, MD, PhD

As a female physician it’s essentially a rite of passage to have a patient mistake you for a nurse, a technician, or another type of non-physician role. Despite introducing myself as “Dr. Chary” in every encounter, patients still mistake me for a nurse or someone in a non-clinical role. My female attending mentors, decades into their clinical careers, tell me that this experience does not go away over time — even if you wear a white coat, sport a “DOCTOR” badge, and hand out business cards with your professional title.

Early in residency I found this experience frustrating. When I expressed misgivings about being confused for a non-physician, my colleagues’ first assumption was that I was offended that my years of education and personal sacrifice were being disregarded. To some degree, that was true, but it felt less about me specifically and more about being a woman in medicine facing daily sexism: I found the pervasiveness of implicit gender bias tiring. We’ve been socially conditioned to imagine physicians as males — often white males — and when someone’s

appearance deviates from that, it simply doesn’t fit into our doctor schema. We’ve also been socially conditioned to imagine women in caregiving roles. Indeed, throughout residency, some of my colleagues encouraged me to reframe role confusion as a compliment. Nurses tend to provide patients with emotional support and care, isn’t it nice that patients associate you, as a woman, with that? Early on in residency, as patients mistook me over and over again for a non-physician, I quickly came to realize that offense was not actually at the heart of this experience for me.

What concerned me more was how role confusion can lead to poor patient care or perceptions of poor care. The first patient I saw as an intern had chronic lower extremity paralysis. After I finished my history and physical exam, she asked for my help getting her on a bedpan, a task I had minimal experience with. When I inevitably struggled, alone, to get the patient situated, she exclaimed, “What kind of nurse doesn’t know how to get their patient on a bedpan?” Reintroducing myself as a doctor led to a slew of questions about where I had gone to college and medical school. What upset me about this situation was not merely being mistaken for a non-physician. It was also that my patient perceived she was receiving poor quality nursing care. My inability to perform the task quickly and efficiently led her to question not only my capabilities, but my institution’s reputation. As a senior resident on a busy overnight, I once held an extensive discussion with a patient’s brother about her prognosis and goals of care in the setting of catastrophic illness and minimal response to emergency therapies. I had introduced myself as the patient’s doctor the first time I walked into the room to assess the patient and begin leading her

resuscitation. I reintroduced myself as “Dr. Chary” when initiating the goals of care conversation. After we had spoken for about 15 minutes and he had come to the decision to transition to comfort measures, he surprised me with: “Thanks for going through this with me. When is the doctor going to get here?” What’s dangerous about the aforementioned situation is the potential confusion over a life-and-death care plan. The patient’s brother thought I was one of the nurses and what he had communicated to me — comfort measures only — was what would go in as a physician’s order on my end, but he was still apparently waiting to speak to a physician to finalize this decision. I’ve had patients complain, hours into their emergency department stay, that they still hadn’t met a doctor—because they met me, my female attending, and a female consultant, but had not yet met a male physician. I’ve had patients, whom I’d seen within five minutes of their arrival, voice concern that they weren’t quickly evaluated by a doctor for what they thought was an emergency. I often looped back into these rooms to clarify my role and attempt to reassure patients that we were working hard to provide them with excellent care. I feel I have an obligation to my patients and my

institution to do so, and perhaps to the more progressive society that I hope to create; yet, each time I do this, it drains me of emotional energy, and I wish I didn’t have to. I don’t blame my patients for forgetting my name or my role. In the emergency department, most people are in crisis mode and it’s difficult to assimilate new information. I also greatly value the nurses, techs, and environmental services personnel who are my colleagues, and my concern over being mistaken for them does not stem from a devaluation of them. We depend on each other’s input, insights, and skills to provide our patients with high quality care as a team. However, assumptions that I serve in another team member’s professional role, rather than as a physician, can do my patients harm. This is why it’s important for my patients to know I am their doctor.

ABOUT THE AUTHORS Dr. Chary is chief resident, Harvard Affiliated Emergency Medicine Residency.

SAEM Foundation’s Annual Alliance Is Investing in a Brighter Tomorrow for EM Through Research – Will You Join Them? At a time when the life-saving importance of emergency medicine has never been more widely understood, less than one percent of National Institutes of Health (NIH) funding supports research in the specialty. The COVID-19 pandemic shines a light on the need for expert, evidencedriven care in medical crises from the everyday to the epidemic—and the quality of that care depends on the strength of the research that supports it. The SAEM Foundation is our specialty’s leader in funding research that empowers emergency physicians, saves lives, and improves outcomes for patients

everywhere. At a time of great need, we’re ready to make a large research investment in our specialty’s future. A cohort of dedicated SAEM members, the Annual Alliance, is forging a philanthropic coalition that will lead to more discovery and launch the careers of future research leaders who will carry forward the specialty and EM patient care in new and better ways. Browse our new SAEMF Donor Guide to learn about the Foundation’s impact, our researchers and the work they are doing, and how you can join your colleagues in supporting a bold vision for EM research.

The SAEM Foundation and Its Annual Alliance Donors Make a Tangible Impact James F. Holmes, Jr., MD, MPH 2020–2021 SAEM President Professor and Vice Chair for Research Department of Emergency Medicine University of California, Davis

It started with an SAEM Foundation Research Training Grant and led to so much more… “The first external grant I received was the SAEMF Research Training Grant. This grant allowed me to develop my research skills including obtaining a master’s degree focused on Epidemiology and Biostatistics. Perhaps more importantly, the SAEMF grant allowed me to obtain preliminary data that led to multiple federal grants including a $1.3 million grant from the Centers for Disease Control and Prevention and a $900,000 grant from the Emergency Medical Services for Children. My current NIH R01 is the line of work initially supported by SAEMF. The SAEMF grant not only provided protected time to develop research skills and preliminary data but also gave me the confidence that I could be successful competing for future grants. The grant essentially launched my research career.” Learn more about Dr. Holmes and other Foundation Success Stories in our new Donor Guide.

Thank You to Our Enduring Donors! Enduring Donors This year, as part of a newly developed plan to strengthen and diversify the financial support necessary to elevate research and education grants funding, we established a new level of the Annual Alliance known as the Enduring Donor level, and our Major Gifts Committee have been visiting with longtime supporters about this new opportunity to champion research. Our donors are answering the call to increase their own personal support by signing on as Enduring Donors. Together with the strength of our endowment — and our entire cadre of Annual Alliance Donors — our Enduring Donors are positioning us to make the biggest leap forward in research funding in our foundation’s history.

We are grateful to the following Enduring Donors who are leading the way to a stronger specialty through their generous giving.

Michelle Blanda, MD

Gail D'Onofrio, MD and Robert Galvin

James F. Holmes, Jr., MD, MPH

James J. McCarthy, MD

Ali S. Raja, MD, MBA

Megan N. Schagrin, MBA, CAE, CFRE

Joseph Adrian Tyndall, MD, MPH

Gregory A. Volturo, MD

Richard E. Wolfe, MD In memory of Peter Rosen, MD

Brian J. Zink, MD In memory of Audrey Zink

Please join us in saluting the generosity and visionary spirit of philanthropy of our Annual Alliance Donors!

Donate Today!

Thank you to our Sustaining Donors! On behalf of the SAEMF Board and our grantees, we extend gratitude to our Sustaining Donors who have made a significant gift to ensure more and larger grants are possible in the future.

Sustaining Donors

Thomas C. Arnold, MD

Steven L. Bernstein, MD

Steven B. Bird, MD

James E. Brown, Jr., MD

Charles B. Cairns, MD

Brian Hiestand, MD, MPH

Robert S. Hockberger, MD

James W. Hoekstra, MD

Amy H. Kaji, MD, PhD

Nathan Kuppermann, MD, MPH

Michelle Lall, MD, MHS

Louis J. Ling, MD

Ian B.K. Martin, MD, MBA

Roland C. Merchant, MD, MPH, ScD

Angela M. Mills, MD

Andrew S. Nugent, MD

Ali S. Raja, MD, MBA, MPH

Niels K. Rathlev, MD

Michael Runyon, MD, MPH

Kirsten L. Rounds, RN, MS

David P. Sklar, MD

J. Scott VanEpps, MD, PhD

Anonymous Donor

Thank you to our Advocate Donors! In addition to all of our Annual Alliance donors, we’re especially grateful to have the support of the Annual Alliance’s Advocate Donors, many of whom have stepped up this year to increase their commitment given the critical need articulated in the 2021 SAEM Foundation Donor Guide. Can we count on you to become an ally for EM research?

Donate Today!

• Srikar R. Adhikari, MD, MS

• Jim Comes, MD

• Joseph Miller, MD

• Harrison J. Alter, MD, MS

• Deborah B. Diercks, MD, MSc

• Nicholas M. Mohr, MD, MS

• Andra L. Blomkalns, MD, MBA

• Gregory J. Fermann, MD

• Robert W. Neumar, MD, PhD

• Chris Carpenter, MD, MSc and Panechanh Carpenter

• Nina Gentile, MD

• Brian J. O'Neil, MD

• Azita Hamedani, MD, MPH, MBA and the BerbeeWalsh Department of Emergency Medicine

• Edward A. Panacek, MD, MPH

• Jeffrey M. Caterino, MD, MPH • Theodore Chan, MD • Anna Marie Chang, MD • Carl R. Chudnofsky, MD and Keck School of Medicine of the University of Southern California • Wendy C. Coates, MD

Paul S. Auerbach, MD, MS

• Thomas R. Hellmich, MD • Babak Khazaeni, MD • Kevin Kotkowski, MD, MBA • Phillip D. Levy, MD • Robert F. McCormack, MD

Cherri D. Hobgood, MD

Robert S. Hockberger, MD

Andy S. Jagoda, MD

David P. Sklar, MD

Brian J. Zink, MD

• Arthur M. Pancioli, MD • Peter S. Pang, MD – in honor of Yung-soo and Jungsook Pang • Elizabeth M. Schoenfeld, MD, MS • Peter E. Sokolove, MD • Jody A. Vogel, MD, MSc, MSW As of February 18, 2021

SAEMF Legacy Society Founding Donors: Strengthening EM’s Future Through Philanthropy Today Another visionary group of SAEM members, our Legacy Society Founding Donors, have each made the decision to ensure that the work of this organization, which they helped build and which has made such an impact on their own professional lives, continues well into the future. Stay tuned to SAEM Pulse for future updates from our Founding Donors who will share a bit more about the “whys” and “hows” of their planned gifts. It may be easier than you think to make this gift. And, if you’ve already made similar plans, please let us know so that we may honor you as a Legacy Society donor. Contact Julie Wolfe at jwolfe@saem.org. 49

ADVICE FOR CONTRACT NEGOTIATIONS FROM A HEALTH CARE ADMINISTRATOR TURNED PHYSICIAN - PART 2 By Aaron Kuzel, DO, MBA This is the second part of an article featured in the JanuaryFebruary issue of SAEM Pulse. Part one of this article may be accessed here. Dr. Kuzel: When you are looking at a contract for the first time, whether it’s your own contract or a colleague’s, what are you looking for in the contract to either maximize a physician’s revenue or protect the physician? Dr. Winterton: It depends on what the physician’s goals are. The first thing I look for is the location, whether the employer is a group or hospital, and how aggressive is this organization needing this type of doctor in this area. For example, if you’re wanting to practice in rural America as an ER physician, the ball is already in your court. If I see a contract from a rural hospital where the physician is under compensated with few perks or benefits, then I relay to the resident or physician that this organization is trying to take advantage of them. I show the resident what the data shows where the 75th, 50th, and 25th percentile are in terms of compensation and advise them to counter with a higher offer and more requested benefits. I also look for how the contract affects the physician’s work-life goals. For example, I had a physician who presented me with her contract who wanted to keep the door open to having children in the next few years. However, her contract contained a legal binding clause that she had to work 40 hours per week for three years. This cuts her option if she wanted to cut back to have children or raise her children in a year or two. She didn’t catch that going through the contract on her own because she thought this was a typical contract and because I pointed this out to her, she was able to make a more informed decision. Dr. Kuzel: What power do physicians and residents have when negotiating their contract and what do they not have any control over? Dr. Winterton: Physicians have the most control over their compensation, their benefits, and their hours of obligation to be on duty. You don’t have so much power to control the legality terms such as liability insurance or the requirements to see Medicare patients. However, compensation, benefits, and hours of obligation are often the parts of the contract physicians are most disgruntled with but have the most control over.

"ALLOW THAT CONTRACT TO BE A TOOL TO HELP YOU ACCOMPLISH YOUR GOALS INSTEAD OF THAT CONTRACT HANDCUFFING YOU TO KEEP YOU FROM WHAT YOU WANT TO ACCOMPLISH." Dr. Kuzel: It seems that in your experience that physicians have more negotiating power than what we seem to think, with that being said, why do you think so many physicians are so disgruntled with their contracts? Dr. Winterton: I think they don’t realize how much power and control they have with their contracts until after they sign it. I have visited with physicians who are 20 to 30 years in practice and they are still learning each contract they sign. On the administration side, however, we know all these options going in and we are not going to hand over all those possible options to the physicians so they can use them to their advantage. When residents speak with colleagues at conferences they find out if they’ve been taken advantage of. With one attending I worked with, when he compared his work with his colleague from fellowship, we found that this attending worked more hours, but received less pay. The reason that separated these two was that the other attending was more aggressive in his contract. I hate seeing that because I know how hard it was to get through medical school and residency; you work too hard as an attending to be taken advantage of. There is definitely some bitterness with the traditional mantra of administration versus physician. It’s hard to trust an administration when you’ve been burned like that starting in. I’ve been on that side [administration] and I hate that us versus them mentality.

Dr. Kuzel: Following up on the expertise aspect of contracts, how does a contract consulting firm differ from a contract attorney in seeking legal advice on a contract? Dr. Winterton: That’s a great question. A contracting firm, whether its financial firm or health care administration such as myself, cannot provide any legal advice or consultation. A contract lawyer can help you with things like a non-compete clause or, if you are working in an academic center, proprietary rights to products developed or research. Contract lawyers are really great in helping you adjust the terms of your contract, but in my experience not all attorneys are great in adjusting your compensation and benefits. Attorneys are excellent at negotiations since their livelihood comes down to this in the courtroom, so they can be excellent assets when evaluating your contract. But I’ve visited with multiple attendings who had previously hired contract attorney’s and they received minimal if not any help with the areas of compensation, benefits, and hours of obligation. Someone like myself who has experience in these areas can make all the difference for a physician looking for a better contract. Dr. Kuzel: While all these services seem great and beneficial, this seems pretty expensive especially on a resident salary. Dr. Winterton: It’s expensive to spend $500 for a consultation or with some very successful firms can charge you $1500 to $2000 for a contract consultation. This is a lot of money upfront. I get that as a resident your budget is really tight. However, how much have these residents spent on their training and education to this point? If this individual can help you double your sign on bonus from $10,000 to $20,000 you’ve already increased your compensation by $10000 for a $500 consultation. If this individual can help adjust your compensation by $5,000 each year for a three-year contract, that’s $15,000. For a reasonably priced consultation service of $300-$500 this is a great return. I have had a couple of physicians who had previously spent thousands of dollars for an attorney consultation and received minimal guidance and feedback. I think it is wise to get quotes upfront and ask “how this individual is going to help me?” Dr. Kuzel: Do you think that there is some connection between physician burnout and their contracts?

Dr. Winterton: Many physicians are altruistic, their primary motivation to going into medicine is to help people. Physicians don’t like to put others off and really struggle standing up for themselves because of that mentality. I think this is a huge factor of burnout because physicians aren’t taking care of themselves, they’re just putting other people first all the time. While this is virtuous, you can’t help others when you are a mess in terms of mental health and financial health. If you’re worried about your debts all day every day, I guarantee that you are not working at optimum performance for your patients worrying about financial obligations. Dr. Kuzel: Thank you so very much for taking the time to speak with us today and for your work empowering physicians and being a physician advocate. Do you have any departing advice for emergency physicians and residents? Dr. Winterton: My advice, for EM or any specialty, is to make a five-year plan and a list of the five things you want in your life. Is it work-life balance? Is it financial independence? Is it student loan forgiveness? Is it the opportunity to work with medical students or residents? First figure out what you want, and then go after a contract — not the other way around. A contact should be a tool to help you accomplish your goals, not handcuffs to restrain you from reaching your goals.

ABOUT: r. Winterton is the founder and CEO of White D Coat Consulting. Dr. Winterton is a graduate of Lincoln Memorial University-DeBusk College of Osteopathic Medicine and is a PGY-2 internal medicine resident at the University of Missouri department of medicine. Dr. Kuzel is an emergency medicine resident at the University of Louisville School of Medicine. He is the associate editor of the RAMS Section of SAEM Pulse and is a member-at-large on the SAEM RAMS Board.

FIVE TIPS TO TRANSFORM MEDICAL STUDENTS AND RESIDENTS INTO SELF-DIRECTED LEARNERS By Ryan O’Neill and Allison Beaulieu, MD on behalf of SAEM Residents and Medical Students As COVID-19 has moved our didactic sessions out of the classroom and into our homes, more emphasis has been placed on self-study and asynchronous learning. Although we anticipate some form of in-person learning to return, it is likely that a new hybrid model for graduate medical education will exist in the future. Self-directed learning is based on the assumptions that adult learners are self-dependent, intrinsically motivated, and rely on past experiences to build on an existing knowledge base. This guide will give all users the tools needed to become a successful self-directed learner in residency and beyond!

Begin with a Self-Assessment

Where to begin? From managing a cardiac arrest to delivering a baby, emergency medicine physicians are responsible for an incredibly large breadth of knowledge and must be able to perform a diverse range of procedures and skills. It can be daunting to find a launch point for self-study; however, by starting with a self-assessment, you will be able to narrow and

refine your focus. Seek feedback. Regularly seek feedback from your attendings and peers. You can ask for both written and verbal feedback. What do they see as your strengths? What could you improve upon? Do they see any gaps in your knowledge? Reflect. Whether you are on shift or attending conference, take time to reflect and fully understand the problem at hand. What do you need to clarify? What do you already know? How can you build upon this knowledge? Self-monitor. Self-monitoring includes your personal judgement of your abilities and awareness of a situation. How did that case go? What went well? What could be improved? What adjustments should you make? Ask for help. If you begin to feel overwhelmed or have difficulty with this initial step, understand that you do not have to do this alone. This skillset takes time to develop. It is okay to ask for help from faculty or peer mentors to refocus your learning efforts.

Create Goals and Objectives

After performing a self-evaluation, you can utilize the SMART framework to create a targeted outline to achieve your learning goals and objectives: Specific. What action will be performed and by whom? Measurable. How will success be measured? Quantify your anticipated results. Attainable. Is the objective achievable within a given time frame and with the resources available? Relevant. Do the objectives align with the instructional method and assessment? Time-bound. When will the objective be achieved? Create a timeframe for when the objectives will be met. A goal is a broad, generalized overview of a desired outcome. For example, your goal may be to achieve a higher score on the in-training examination. Objectives are the finer details that outline the process of achieving your desired outcome.

Identify Resources

With your goals in mind, the next step is to identify what types of resources will be used to achieve them. We have access to more educational content than ever before and it can be easy to get lost in the weeds. This abundance of resources, however, also allows you to pick and choose those that best fit your preferences. Whether you prefer reading textbooks, utilizing question banks, or listening to podcasts, it is essential to evaluate which resources will best help you achieve your goal. SAEM and ALIEM have compiled comprehensive lists of resources. You can also consider utilizing the Social Media Index. This is a comparative index, similar to the impact factor, that has been shown to correlate with quality and can be used to identify reliable FOAM resources. When in doubt, do not forget about utilizing the human resources in your life. Peers and mentors can oftentimes point you in the right direction when navigating this process. While it could be tempting to try and use every resource you find, there is only so much time in a day, and it is best to choose a few resources that work best for you and stick with them.

Employ Learning Strategies

At its core, learning is the storage and retrieval of information. There are multiple learning strategies that can be utilized to enhance this process: Multimodal learning is a form of studying that uses multiple resources in varied formats. These formats could include textbooks, podcasts, videos, and more. This learning strategy not only provides repetition when learning a topic, but also allows you to process the same concepts from different perspectives. Interleaving refers to studying different topics simultaneously. Of all specialties, this learning strategy seems most relevant to emergency medicine. By studying multiple topics at once, both old and new, we are challenged to retrieve disparate bits of information. This challenge enhances our learning and provides an opportunity to draw previously unseen connections between topics.

"SELF-DIRECTED LEARNING IS BASED ON THE ASSUMPTIONS THAT ADULT LEARNERS ARE SELF-DEPENDENT, INTRINSICALLY MOTIVATED, AND RELY ON PAST EXPERIENCES TO BUILD ON AN EXISTING KNOWLEDGE BASE." Spaced repetition is the practice of intermittently reviewing previously learned material. Over time, we are more and more likely to forget information we have acquired. By periodically reexposing ourselves to these concepts, we not only prevent this forgetting but also reinforce our understanding of them. Active retrieval challenges us to access the information we have already learned and apply it. This learning strategy can be done through flashcards, quizzes, and patient cases. By pushing ourselves to retrieve and utilize concepts, we strengthen our ability to do so again in the future, ultimately improving our clinical application of what we have learned. Emergency Medicine Cases has a great podcast and article that dives further into this topic.

Evaluate Progress

Congratulations! You have taken the necessary steps to become a reflective, active, self-directed learner. At this stage you will evaluate whether or not you achieved your learning objectives and review what adjustments you can make in the future. Continue to work at this process. You will find the more time you take for self-assessment, creation of SMART goals, review of educational materials, and implementation of learning strategies, the more you will improve. The process of becoming a self-directed learner does not end here — continue to refine your skills in becoming a life-long learner! ABOUT THE AUTHORS: Ryan O’Neill is a fourth-year medical student at The Ohio State University College of Medicine.

Dr. Beaulieu is a first-year Medical Education Fellow and clinical instructor of emergency medicine at The Ohio State University Wexner Medical Center.

EM PHYSICIAN SCIENTIST TRAINING PROGRAMS: OPPORTUNITIES FOR RESIDENTS COMMITTED TO CAREERS IN EM RESEARCH By Rachel Dahl, MS and Muhammad Waseem, MD

Summary

What is a physician-scientist?

PSTPs are not fellowships, rather they are noncredentialed professional programs that offer a formal organizational structure of support throughout residency for residents committed to careers in research. PSTPs are distinct from residency programs, but their timeline is integrated within and after residency to be able to support young physicianscientists at every step of their transition toward becoming an independent researcher.

Why choose to apply to a PSTP?

Emergency medicine (EM) continues its growth spurt without knowledge of what it will look like as it matures. Perhaps one example that exemplifies EM’s growth is the recent development of physician-scientist training programs (PSTPs) with an EM-focus.

This article introduces the role of physician scientists and PSTPs as well as why EM is such an exciting area for physician-scientist training. It includes perspectives comparing PSTPs to other routes to the physician-scientist track, such as research fellowships.

Physician-scientists are physicians (MD/DO/MBBS) who are committed to incorporating a significant percentage of research time in their career. Most have had significant research experience during their overall training, evidenced by completing a PhD, MS/MSc with thesis work, or equivalent experience. Physician-scientists more often work in clinical research than in lab or bench research, and the majority work in academic hospitals. Though the percentage of time devoted to research vs. clinics can range, a recent study looking at job outcomes of MD-PhD graduates indicated that about 56% of physician-scientists who work at academic institutions spend a minimum of 50% of their work time in research. For young physicians truly committed to a career involving research and who want to establish their own lab or research group after completing residency, PSTPs are a desirable option for moving toward that path. PSTP organizational support generally offers all of the following:

• protected research time to work on projects and develop one’s scientific skill set throughout residency; • extra financial support to attend and present research at conferences; • networking opportunities to connect with experts and potential mentors in one’s area of interest; and • assistance with applying for institutional funding and Federal grants, such as a K01. Dr. Nicholas Mohr, emergency department research director at the University of Iowa, says “what makes an applicant competitive for a PSTP is that they have a strong career of vision. It’s not a particular degree that makes you competitive, it’s that you have an idea of where you are going, that you have an idea of how you’re going to get there, and that you have some concept of how the PSTP pathway fits into that vision.” Dr. Mohr continues, “we’re looking for someone who has advanced research training already, we look for people who have had some research experience, and where that experience has some connection to what they convey their future career is. A lot of this is about passion to make the world better, passion to make the specialty better, and a passion to learn things that we don’t know already.” Participating in a PSTP may either extend the duration of residency or it can last a few years post-residency. PSTPs that extend residency may include salary perks that aim to offset the longer duration of training on a resident salary, and likewise may offer the participant an increase in salary equivalent after graduating from residency for the remaining years in the PSTP. PSTPs are variably funded, such as by in-house support, NIH T32 training grants, and more. An additional benefit to participating in a PSTP is the ability to interact with other new physician-scientists in PSTPs of different disciplines during regular planned social events and academic seminars. This increases opportunities to share ideas and to collaborate between different specialties. Interspecialty collaboration lends itself well to thinking outside the box, which might be particularly beneficial for EM research, which may include a mix of aspects from every medical specialty. From an organization’s perspective, PSTPs may offer one way to identify potential candidates for future faculty positions. Additionally, PSTPs may offer subtle benefits for members of the department who are not actually participating in the PSTP. Dr. Nick Mohr says that offering a PSTP is “one way to be really explicit about what the priorities of our department are, what the priorities of our institution are. At University of Iowa, one of our priorities is to train excellent emergency physicians who are going to go out and take care of patients, but one of our priorities really is to continue to change the practice of medicine and to train the next generation of clinician-investigators. And I think that that’s something that is important for residents in our program who are not part of the PSTP, because they are entering a culture where we have this tripartite mission. I think that it is also important for our department to really prioritize creation of new knowledge, dissemination of new knowledge in our own practice of emergency medicine.”

"PHYSICIAN-SCIENTISTS ARE PHYSICIANS (MD/DO/MBBS) WHO ARE COMMITTED TO INCORPORATING A SIGNIFICANT PERCENTAGE OF RESEARCH TIME IN THEIR CAREER." Challenges to a PSTP

New MD/DOs may shy away from the longer duration of training associated with a PSTP track, particularly when they lack role models or mentors who can answer questions about the difficulties of pursuing a dual career. Mentorships are crucial, in part to be able to discuss issues such as work-life balance and self-care with an experienced person who has dealt with similar challenges. Mentors also play a critical role in helping new physician-scientists learn the ropes of obtaining funding, figuring out ways to balance academic versus clinic time, finding the right fellowship, and so forth. The lack of and need for role models and mentors for physician-scientists in all medical specialties is a problem that the NIH has openly recognized, with concern that this contributes toward the continuing depletion of the number of U.S. physician scientists, boding poorly for our ability as a nation to continue to remain at the forefront of scientific medical breakthroughs. Finding a mentor as a physician-scientist is even more of a challenge within newer academic areas such as EM, simply because of its novelty. Participating in a PSTP can facilitate the ability to find connections to experienced mentors through organizational networks of the faculty who support the PSTP. For some residents, a drawback to pursuing the physicianscientist track is that less time is dedicated to patient care. Additionally, there is the burden of time and energy dedicated to generating funding for research and the well-known longterm compensation disparity compared to non-academic positions. Generally, physicians who opt for a physicianscientist career path in academic medicine are cognizant of the long-term compensation disparity compared to their private practice peers. They have to decide whether the differences in compensation and patient care are balanced out by the benefits associated with working in an academic hospital, such as the security of tenure, the opportunity to grow as a leader in the field, the ease in finding collaborators, and fundamentally the potential to expand and shape the future of EM through research and teaching.

continued on Page 56

TRAINING PROGRAMS from Page 55

Why is EM such a unique specialty for a physician-scientist?

Evidence-based medicine is at its strongest in EM, where critical, algorithmic decision-making is best informed by the most ground-breaking epidemiologic research. Further, the broad nature of EM lends itself to a unique variety of myriad research opportunities, such as improving our understanding of cardiopulmonary physiology, aiming to optimize prehospital to hospital care, and developing the intersection of EM with community health. This makes EM one of the most exciting fields to study, with great capacity for growth for physician-scientists. Dr. Nick Mohr agrees that the breadth of potential topics in EM research is part of its value: “EM research is not a narrow clinical specialty. There is no reason that we need to view it as only to study things that we can use clinically in an emergency department. It is medicine more broadly, it is answering questions significant for public health, it is answering questions that are significant for making the lives of our patients better, and that crosses a lot of boundaries.” Dr. Sara Krzyzaniak, associate professor at Stanford University and program director of emergency medicine residency, also agrees: “I think that emergency medicine is beautifully broad. We touch so many different parts of healthcare, patient’s lives, everything from those social determinants of health through the pathophysiology of disease, we cover all of that, and we cover all of these different fields. Yes, we’re resuscitation specialists, but we also take care of transplant patients, we take care of cancer patients, we take care of all these different groups of people, so I think that the possibilities for a physician-scientist in emergency medicine is really broad. And I think that the

understanding that you get going through EM residency I think really prepares you to be able to look at that whole picture.” In addition to the advantage of the wide breadth of potential topics, Dr. Mohr also believes that the clinical schedule of the emergency physician is appropriately complementary to a research career: “With a lot of things, being able to have uninterrupted laboratory time, writing time, is critical. And it’s something that I think really works well with the EM clinical schedule.”

PSTP vs. Academic Fellowship vs. Research Electives/Track in Residency

Part of what makes PSTPs unique from academic fellowships is its integration throughout the residency timeline. This generally allows for longer continuity on the same project during residency, while at the same time, the residentphysician-scientist is building professional relationships. However, other options are available for pursuing a physicianscientist track outside of participating in a PSTP, such as participating in research electives during residency or participating in academic fellowships after residency. For example, one route is to use residency electives to participate in research projects or research tracks. Dr. Sara Krzyzaniak explained that Stanford’s EM ACCEL program allows a lot of flexibility for research within the EM residency: “Our ACCEL program does allow someone interested in research to commit dedicated time to this endeavor, but it’s not a formal PSTP program. As a program we have some of the most elective time in the country of four-year programs, and so the ACCEL pathway is a way to structure that elective time such that we are encouraging our residents and supporting them so that they have a pathway trajectory through all of this elective time, and hopefully at the end of four years have provided them with a cohesive thing that they have done with that time. Within the ACCEL program

Table 1. Integrated EM PSTPs and Residencies* PROGRAM Dedicated time for research during residency Salary bonus/ Funding for travel and conferences

UNIVERSITY OF IOWA PSTP

NORTHWESTERN PSTP

Four months of dedicated research time in PGY1-PGY3 years.

PGY-1, PGY-2 focus is on clinical development, exploring interests and opportunities, connecting with potential mentors. PGY-3, PGY-4 include time for dedicated research projects.

Annual academic allowance of $4,000 in addition to travel funds provided to EM residents. This may be used for academic expenses such as books, professional memberships, research supplies, or travel.

Residency duration 3 years

Supplemental funds for travel to conferences, educational and career development courses, and grant-writing courses. 4 years

Other

Guaranteed acceptance to the Department of Emergency Medicine Associate Scholar Program or Clinical Fellowship in the department of EM upon successful graduation from residency.

Program website

https://medicine.uiowa.edu/emergencymedicine/ education/physician-scientist-training-pathway-pstp

https://www.feinberg.northwestern.edu/sites/physicianscientist/pstp-programming/emergency-medicine/index.html

Note: The information in this table was taken from informational websites of each institution during the time of this writing and may no longer be accurate. Please contact institutions directly for current information about each program.

there is opportunity for research, and we have research lines, and as a program in general we have a pretty high research expectation of our residents, but it’s not a true PSTP; it’s not a dedicated year of time to really focus on research. It’s 22 weeks of elective time over the four years of residency, but it all falls into the second, third, and fourth years. We are aiming to create a PSTP program. We only became a department in 2015, so this is something we’ve been in the early phases of creating for several years… and I think we will see a PSTP program in the near future.” Some EM residency programs like at Johns Hopkins University have incorporated a fourth year of residency to include a final year of fellowship-like training in one of EM’s subspecialties (e.g., research, ultrasound, toxicology, etc.) Other programs, like University of Rochester, also offer dedicated residency research tracks. These types of programs include opportunities to participate in research projects as well as may include classes in ethics, grant-writing, survey design, and epidemiology and biostatistics methods. Academic fellowships which offer sustained, dedicated time and support for research and career development, typically over a two-year course after residency, are another option for young physician-scientists. Many of the EM research fellowships incorporate an additional Master’s degree (such as in public health, epidemiology, or clinical investigation) along with financial support, career development courses, mentorship opportunities, academic seminars, and other opportunities. SAEM offers an online RAMS Research Roadmap that includes helpful tips about the EM research track, including research fellowships and funding. Some new EM-focused clinician-scientist training programs (CSTPs) have recently been developed which, similarl to PSTPs,

offer organizational support to assist physician-scientists. These programs are designed for physicians who are already boardcertified, but otherwise offer similar financial and mentorship support as a PSTP. At the time of this writing, the author was unable to obtain perspectives from representatives of these programs.

Summary

The new development of EM PSTPs reflects the growth and potential of EM as an expanding area of research for young physician-scientists. PSTPs offer exciting opportunities for future EM residents who want to contribute to a significant portion of their career as a research scientist. PSTPs are noncredentialed professional programs that are unique in that they offer comprehensive support throughout residency, and potentially beyond residency, to enable transition to independence as a physician-scientist. ABOUT THE AUTHORS: achel Dahl MS is a third-year medical student R at University of Iowa Carver College of Medicine, concurrently completing an online Master’s of Public Health at University of California Berkeley. Rachel plans to become either an Emergency Physician or Trauma Surgeon with additional interests in community and global health. rachel-dahl@uiowa.edu Dr. Waseem is a professor of emergency medicine and pediatrics at Weill Cornell Medical College, New York and research director for the department of emergency medicine and vice chair for the Institutional Review Board at Lincoln Medical Center.

WHY SHOULD I BE INVOLVED IN RAMS? REFLECTIONS FROM THE 2020-2021 RAMS BOARD By Aaron R. Kuzel, DO, MBA on behalf of the SAEM Membership Committee

Jeffrey Sakamoto, MD Stanford University RAMS Secretary-Treasurer I initially applied to the RAMS board to participate in shaping its multifaceted approach to improving the development and training of emergency medicine residents and medical students. Having Jeffrey Sakamoto served on the RAMS board for the past two years, first as a member at-large and now as the secretarytreasurer, I have had many impactful and valuable opportunities in education, leadership, and mentorship. Mentorship is the most important resource available to RAMS members. Interacting with thought leaders and influential members within academic emergency medicine on both the SAEM board and SAEM committees through RAMS has been highly educational. Through the SAEM wellness committee, I have been able to author articles, participate in groundbreaking research, and present on a national level. RAMS has also allowed me to create a network of extraordinary resident and medical student leaders around the country — an invaluable resource both now and after training. Through these connections, I have been able to participate in a coaching pilot project to better develop my leadership skills, present at the annual meeting, and most importantly develop friendships that will last throughout my career. My experience with RAMS has been essential to my development as an emergency physician and I encourage all residents and medical students to take advantage of the unique opportunities RAMS has to offer.

Adrian Cotarelo, MD, MHS St. John's Riverside Hospital RAMS Member-at-Large My work with SAEM/RAMS has been a defining part of my medical school, and now residency experience. I first became involved with SAEM as a Medical Student Ambassador and immediately Adrian Cotarelo became invested in the strong sense of community and resources available through the organization. Through RAMS, I have been able to network with people and institutions throughout the nation, from research projects, didactic submissions, and coordinating collaborative events with other professional EM organizations. I have had the opportunity to moderate several large-scale national events that had to be adapted into a virtual format such as the annual Cocktails with Chairs, webinars, medical students advising sessions, and the first virtual residency fair in the organization’s history. I was able to serve as a board liaison to the SAEM research committee, taking on a variety of projects with research faculty, residents, and medical students from across the country. These experiences I have been able to bring back to my own institution, where I have taken the role of director of resident research. These experiences have been invaluable in providing experience in leadership in the field of academic emergency medicine, alongside forming a closeknit group among the rest of the SAEM RAMS Board.

Alexis del Vecchio, MD The Mayo Clinic RAMS Member-at-Large It's been an absolute joy and privilege to serve on the RAMS Board and represent the interests of our medical student and resident membership. I've seen what true leadership looks like through our RAMS Alexis del Vecchio president Andrew Starnes and SAEM CEO Megan Schagrin, and the ways in which they put every member of our board forward and really bring out the best in everyone so we can accomplish as much as possible for our members. I can only hope to emulate their facile and supportive way with people as I progress in emergency medicine. This position has given me the opportunity, too, to interface with leaders in academic emergency medicine, mentorships and relationships that I will continue to nurture for years. I've learned to develop the confidence to speak up in meetings with big names in emergency medicine, had the chance to moderate one of our RAMS webinars with some of the leading voices in our tight-knit community, and collaborate on numerous initiatives to give a voice to our members. And I'm grateful, perhaps most importantly, for the friendships I've developed with my fellow board members, even if our interactions have all been virtual due to that worldwide pandemic still going on!

Hamza Ijaz, MD University of Cincinnati RAMS Member-at-Large RAMS has been instrumental in increasing my exposure to organized academic emergency medicine. Getting involved with RAMS has allowed me to learn about national issues facing our specialty and Hamza Ijaz how to increase advocacy for our residents and medical students. Through RAMS, I have been fortunate to collaborate with some of the leaders within emergency medicine and have been supported by numerous mentors. RAMS has given me the opportunity to collaborate with individuals I wouldn't otherwise have met. The diverse group of board members that I've been fortunate enough to work with has continued to inspire me. Working alongside the rising leaders within our specialty has taught me numerous leadership skills that I am able to put into clinical practice. Without RAMS, it would have been very challenging to develop such a diverse network in such a short time.

Daniel Jourdan, MD Brody School of Medicine at East Carolina University RAMS Member-at-Large My initial involvement with RAMS began as a student member of the education committee. There I had the privilege of working alongside national leaders Daniel Jourdan to publish a how-to guide for members interested in pursuing a career in medical education. This

was pivotal in advancing my interest in national organizations; it demonstrated that even student members could have an impact by producing materials useful nationwide. As I have grown into my current role as a member-at-large, I continue to be amazed at all the student and resident members can accomplish. Even in the face of the tumultuous year in medical education, RAMS continued to expand productivity. We maintained traditional offerings as possible while pivoting to expand our online presence: initiating new online webinars, increasing production of podcasts and news articles, and hosting an online residency fair. Even more importantly, RAMS became pivotal in national discussions and position statements regarding changes in medical education. While the opportunities to get involved are endless, the best aspect of being on the RAMS Board is the chance to work alongside such amazing student and resident members. Specifically, the possibility of paying it forward by showing other members they too can get involved and impact national policies.

Vytas Karalius, MD, MPH, MA Northwestern University, Feinberg School of Medicine RAMS Member-at-Large The development of the RAMS Board a few years ago expanded the leadership and involvement of residents and medical students in SAEM and academic emergency medicine Vytas Karalius as a whole. I believe the future of emergency medicine is bright, with our youngest members (residents and medical students) already showing incredible promise in their productivity and advocacy for important medical/social issues. I joined the RAMS Board because I wanted to be a part of the RAMS mission to help advance the future of EM through the development of residents and medical students into future academic leaders. My experience on the RAMS Board has been amazing. I have been surrounded by incredibly talented resident-leaders from around the country. Not only has it has been a tremendous learning and growth opportunity for me, it was also inspiring to see how passionate my comembers are. While our board lacked the opportunity to meet in person and workshop during the annual conferences due to COVID-19, I have been surprised at the positive work that has spawned from out virtual meetings. This was also an unprecedented year with the COVID-19 pandemic and racial inequality in the spotlight. I am proud that the RAMS Board took an active role in political advocacy during this most needed time.

Aaron R. Kuzel, DO, MBA University of Louisville School of Medicine RAMS Member-at-Large RAMS offered me my first opportunity in organized medicine as a second-year medical student and I have only continued my involvement in organized emergency Aaron R. Kuzel medicine. I have been honored to work alongside talented resident-leaders and passionate physicians who work to advocate for our specialty and our patients. RAMS has offered so many opportunities to be involved including mentorship opportunities, leadership development, networking, and a platform to advocate for the patients we serve. RAMS has provided me opportunities to work with many incredible academic physicians in our specialty and to work with them to solve the issues most pressing to our specialty.

Wendy W. Sun, MD Yale-New Haven Health RAMS Member-at-Large RAMS is important to me because of its mission to cultivate the next generation of emergency medicine leaders, provide academic opportunities, and facilitate mentorship relationships. As a board member for the Wendy W. Sun past two years, I’ve grown as an EM physician because of the meaningful projects I’ve been able to contribute to and the opportunities to collaborate with and learn from EM role models who are so willing to mentor. RAMS has truly jump-started my EM career.

Ryan D. Pappal Washington University, St. Louis School of Medicine RAMS Medical Student Representative Since I first trialed the medical field after high school by training in EMS, practicing emergency Ryan D. Pappal medicine has been a long-term goal of mine. Considering both my interest in emergency medicine and my commitment to clinical research, I’ve found a home in SAEM RAMS. From my work as a member of the Research Committee to serving on the RAMS Board as a clinical medical student, I’ve found myself a sense of purpose, all while surrounded by some of the kindest and hardest-working leaders in the field. SAEM RAMS has given me the opportunity to reach leaders and trailblazers in emergency medicine to help further our overarching goal to support residents and medical students interested in emergency medicine. As I look forward to my goal in becoming a leader in academic emergency research, SAEM RAMS has been instrumental in building the connections and leadership skills necessary to make a meaningful impact on emergency practice in the future.

Dhriti Sooryakumar The Ohio State University School of Medicine RAMS Medical Student Representative Being part of RAMS and serving on the RAMS Board has been an incredible experience for Dhriti Sooryakumar me. Emergency Medicine is one of my greatest passions and having the opportunity to be part of and have a voice in one of the most renowned emergency medicine organizations globally has been an honor. I have had the unique opportunity to work alongside the leaders in emergency medicine while serving my medical student and resident peers. It has been an honor this year to help my fellow medical students navigate the unprecedented challenges of clinical rotations and a virtual interview season amidst Covid-19. I was able to create and lead webinars as well as formulate ideas for future workshops and educational opportunities to ease the transition for medical students into residency. Additionally, serving on the awards committee as the RAMS Board representative and creating new awards for under-represented minority medical students was a truly fulfilling experience, knowing that I am helping provide much-needed educational funding for my peers. Overall, my experience on the board has been an invaluable one. It has been one through which I have created wonderful friendships, professional collaborations, and the start to what I am certain will be a lifetime journey with our incredible organization. I am very grateful for this opportunity.

HUMAN TRAFFICKING: IDENTIFYING AND TREATING VICTIMS By Nicole E. McAmis, Angela C. Mirabella, Elizabeth M. McCarthy, and Cara A. Cama, Frank H. Netter MD School of Medicine, Quinnipiac University on behalf of SAEM’s Residents and Medical Students

Summary

The U.S. Department of State defines human trafficking in The Trafficking Victims Protection Act of 2000 as sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age; or the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery. Human trafficking is a violation of human rights and a global pandemic. Emergency physicians are often the first group of health care professionals to interact with victims of human trafficking with over 88% of victims seeking medical care in a variety of health care settings. Emergency physicians will likely encounter victims of human trafficking at some point in their careers and will be called upon to provide not only medical care for various concerns, but also emotional and psychological support. Victims of human trafficking may present to emergency departments for a myriad of medical complaints including infectious diseases, physical violence, sexual abuse, pelvic pain, hazardous working conditions, unintended pregnancies, abortions, malnutrition, dental disease, anxiety, chronic pain, posttraumatic stress disorder (PTSD), depression, substance use disorders, suicidal ideations, or suicide attempt. Unfortunately, many emergency physicians lack the knowledge and tools needed to recognize these victims. In this article, we will dive into some basic information that all health care providers need to identify and provide treatment to victims of human trafficking.

Risk Factors

It is often difficult to identify those individuals who may be victims of human trafficking. However, we provide certain risk factors that could assist in the identification of human trafficking victims:

• Poverty • Racial/ethnic minority status • Marginalized individuals (LGBTQ, runaway youth, Native Americans, indigenous people) • Rural location • Lack of education • Disability • Inadequate family support and protection • Migration

Red Flags and Indicators of Human Trafficking

• Someone else is speaks for the patient and refuses to let the patient have privacy • The patient exhibits fear, anxiety, or tension • The patient is reluctant to explain his/her injuries or they share a scripted/inconsistent history • Tattoos or other forms of branding are visible on the patient • The patient reports an unusually high number of sexual partners, STDs, pregnancies, miscarriages, or terminations • Language [or slang] is used that is common in the commercial sex industry (Examples of such terms can be found here: Know the Language of Human Trafficking: A Glossary of Sex Trafficking Terms (amuedge.com))

Screening Tools and Questions

Once you have identified these red flags, the next step is to provide screening questions to your patient: • What are your working or living conditions like? • Have you ever been deprived of food, water, sleep, or medical care? • Can you leave your job or situation if you want? • Can you come and go as you please? • Who is the person who came with you today? Can you tell me about them? • Have you ever been threatened or intimidated? • Has anyone threatened to hurt you or your family if you leave? • Do you have a debt to someone you cannot pay off?

• Is someone holding your identification documents (passport, visa, driver’s license)? • Did you ever feel pressured to do something that you didn’t want to do or felt uncomfortable doing? • Have you ever been told to have sex with people you don't want to have sex with? • Have you been forced to engage in sexual acts for money or favors? • Does anyone take all or part of the money you earn? • Do you have to meet a quota of money each night before you return home?

How to Approach These Questions

It is always important to conduct the assessment in a comfortable, private location with a social worker or advocate present whenever possible. Prior to beginning the interview, be sure to start with three simple questions to ensure the safety of the victim: 1. Is it safe for you to talk with me right now? 2. Do you feel safe right now? 3. Do you feel like you are in any kind of danger for speaking with me? When possible, conduct the interview in the victim’s native language and use a professional, neutral interpreter if needed. Be sure to use an approachable tone, demeanor, and body language to remain neutral and nonjudgmental. Always assure confidentiality, unless the situation invokes state mandatory reporting laws (the person is in grave danger, a minor under the age of 18, or has disabilities). Also, victims may find it easier to speak with a provider who is of the same sex, ethnicity, or age range. At all times, please be sure to reference existing institutional protocols for victims of abuse.

Next Steps

After addressing the immediate needs of your patient and obtaining informed consent, consider calling the National Human Trafficking Resource Center (NHTRC) hotline at 1-888-373-7888. The NHTRC can help assess the current

level of danger, provide further recommendations, identify local resources, and potentially involve law enforcement. In dangerous or life-threatening situations, follow your institutional policies for reporting to law enforcement and consider the following: • the presence of the trafficker in the patient’s room, waiting room, or home • the potential that calling the hotline may put the patient or the patient’s family in danger • the age of the patient It is vital that you help the patient memorize the phone number, so they can call 1-888-373-7888 or text HELP or INFO to BeFree (233733) at a later time. Avoid giving the patient physical materials including written notes or brochures that could place them at increased risk if detected.

Conclusion

Emergency physicians are in a unique and powerful position to serve as the first responders for victims of human trafficking. This article has provided some tips and tools to utilize in your practice to identify and serve those victims who suffer from human trafficking. Many health care professionals have shared concerns about the lack of quality training available on this topic. Because of this, we sought to identify the self-reported knowledge level of providers on the global issue of human trafficking. Further research should be conducted to further identify successful strategies in preventing and rescuing victims of human trafficking. We hope to present such results in a future publication. ABOUT THE AUTHORS: Nicole E. McAmis, is an MS4, class of 2021, Angela C. Mirabella is an MS3, class of 2022, Elizabeth M. McCarthy is an MS2, class of 2023, and Cara A. Cama, MBA, is an MS4, class of 2021 at the Frank H. Netter MD School of Medicine, Quinnipiac University, Hamden, Connecticut.

Read More! • U.S. Department of State Trafficking in Persons Report June 2019 • Identification of human trafficking victims in health care settings • Health Care Providers’ Training Needs Related to Human Trafficking: Maximizing the Opportunity to Effectively Screen and Intervene • The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities • The health risks and consequences of trafficking in women and adolescents • Minor and Adult Domestic Sex Trafficking Risk Factors in Ohio • Identifying Victims of Human Trafficking: What to Look for in a Healthcare Setting • Comprehensive Human Trafficking Assessment • National Human Trafficking Hotline 61

BRIEFS AND BULLET POINTS SAEM NEWS

Task Force, shared his knowledge and firsthand perspective on the current state of the COVID-19 pandemic.

SOAR Featured Content

Did You Miss Seeing the Fauci Webinar? Catch it Now on Video!

In case you missed it, the SAEM National Grand Rounds: COVID-19 Vaccine Distribution and What It Means for the Emergency Department is now on video! Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID) and one of the lead members of the White House Coronavirus

Check out the variety of presentations from SAEM20, SAEM19, and SAEM18. View dozens of recorded presentations online and save or share your favorites. It’s all part of SOAR: SAEM Online Academic Resources, featuring three years of annual meeting content, more accessibility than ever before, an enhanced, easy-to-navigate layout that allows you to view online education resources or from the SAEM YouTube Channel. Check out this issue’s featured categories! • diversity • global health • geriatrics • informatics/social media • infectious diseases • palliative medicine

SAEM20 Clinical Image Series

The SAEM Clinical Image Series is a collaborative series with ALiEM (Academic Life in Emergency Medicine) and features the winners of the SAEM Annual Meeting Clinical Images Exhibit competition. Check out the images, read the case notes, and see if you can figure out the diagnosis before you reveal the answer. Images from the SAEM20 virtual meeting are posted below; all images will be highlighted throughout the coming year in SAEM Weekly and at the ALiEM website. • Edema Got Your Tongue? by Rykiel Levine, NYC Health + Hospitals/Lincoln Medical and Mental Health Center and Richard Iuorio, MD, Lincoln Medical Center/Weill Cornell Medical College • Sun-burnt Hands and Lips by medical student Justin Rich and Michael Sternberg, MD, University of South Alabama

ARMED MedEd: Developing a Cadre of Health Professions Education Researchers in Emergency Medicine The inaugural session of the Advanced Research Methodology Evaluation and Design in Medical Education (ARMED MedEd) course took place on February 8-9, 2021 via Zoom. This longitudinal course is aimed at health professions education researchers who already have some experience but want to develop their skills in grant writing and in conducting collaborative research with high level outcomes. By the end of the course, each of the participants should have prepared a competitive grant application, and many will have begun their research studies. The course featured faculty both from within the specialty of emergency nedicine as well as internationally recognized health professions education research leaders. SAEM is sponsored the course to support EM education researcher development, advance the science of emergency medicine education, and ultimately benefit learners, educators, and patient care. An innovative, collaborative mentorship program paired each participant with a personal mentor and groups three of these dyads together into a “mentor family.” This structure created a team that can conduct studies at multiple institutions and allows course participants to serve as the PI on their own project and as a coinvestigator on two other projects while gaining skills as a peer mentor. A novel approach to considering equity in education and research debuted as an organized thread throughout the ARMED MedEd experience. Teresa Y. Smith, MD, MEd and her team created a series of educational experiences to enable researchers to minimize the impact of bias in education studies and to make their interventions accessible to learners from all backgrounds. As part of this thread, the team provided a consultation service to researchers as they prepare their research plans. Many of the SAEM academies and RAMS provided scholarships for their members to attend this course and advance research that is related to their missions. The SAEM Foundation created a $25,000 grant earmarked for an ARMED MedEd investigator. The course runs for 15 months and we look forward to hearing about all of the research projects at the graduation at SAEM22, currently scheduled to take place in May 2022 in New Orleans, LA.

• The Insidious Rash by Monica Mitta and Michael Sternberg, MD, University of South Alabama • What Lies Beneath by Jamie Fried, NYU Grossman School of Medicine, Jessica Tsao, MD, NYU Langone/ Bellevue Medical Center, and Lindsay Davis, MD, NYU School of Medicine • Left Ear Mass by Gabriela RiveraCamacho, MD, and Adeline Dozois, MD, Atrium Health – Carolinas Medical Center, Charlotte, NC • Oral Trauma and Mass by Han Wei Zheng, MD, MetroHealth Medical Center, Department of Emergency Medicine, Cleveland, OH

AWAEM and RAMS Announce Collaborative New Webinar Series: From Match to First Promotion

The webinar series, “From Match to First Promotion,” kicked off in January with Gender Biases and Clinical Leadership: Stories, Situation, Skills. The series, brought to you by SAEM, RAMS, and AWAEM, was created to support professional development during these difficult times that challenge our ability to create organic mentor-mentee relationships. In the first webinar, now on video, a diverse panel of speakers discussed workplace biases, imposter syndrome, and clinical leadership skills inside and outside of the resuscitation room ad addressed gender identity and professional development in the practice of emergency medicine.

SAEM JOURNALS The Latest Podcasts From SAEM Journals

January AEM Podcasts • Identifying Maltreatment in Infants and Young Children Presenting With Fractures: Does Age Matter? • Emergency Physician and Advanced Practice Provider Diagnostic Testing and Admission Decisions in Chest Pain and Abdominal Pain January AEM E&T Podcasts • The Teacher, the Assessor, and the Patient Protector: A Conceptual Model Describing How Context Interfaces With the Supervisory Roles of Academic Emergency Physicians • Learner Perceptions of Electronic Endof-shift Evaluations on an Emergency Medicine Clerkship

February AEM Podcasts • Emergency Physicians and Personal Narratives Improve the Perceived Effectiveness of COVID-19 Public Health Recommendations on Social Media: A Randomized Experiment Journal podcasts are also available on iTunes.

SAEM Journals Editor-in-Chief Commentaries for January and February

For each issue of Academic Emergency Medicine (AEM) and AEM Education and Training journal, editors-in-chief Dr. Jeffrey A. Kline and Dr. Susan B. Promes, respectively, select one paper as having particular importance and relevance to the readers of their respective journals. They share their thoughts and observations regarding their selected papers in regular editor-in-chief commentaries. Their most recent EIC pick commentaries are linked: • Protecting the Most Vulnerable by AEM EIC, Jeffrey A. Kline, MD • Stop the Worry: Just Click the Acetaminophen Box and Move On by AEM EIC, Jeffrey A. Kline, MD • Women’s Burden Increases in COVID-19 Era and Female Emergency Medicine Physicians Are No Exception by AEM E&T EIC, Susan B Promes, MD, MBA

The Latest Issues of SAEM Journals Are Ready for Your Review! Full issue PDFs of the May and June issues of Academic Emergency Medicine (AEM) are now available for download... or read the issues online!

• Download a full PDF of January AEM or read online • Download a full PDF of January AEM E&T or read online • Download full PDF of February AEM or read online

SAEM REGIONAL MEETINGS New England Research Directors

Registration is Open for the NERDS Regional Meeting

Registration is now open for the New England Research Directors (NERDS) regional meeting, to be held virtually on Wednesday, April 7, 2021. Now in its 25th year, the NERDS meeting is the primary forum for presenting original emergency medicine research in the New England area. This year’s NERDS meeting is hosted by the University of Connecticut Emergency Medicine Residency and the University of Massachusetts Medical School-Baystate.

SAEM21 UPDATES Check Out the New Issue of SAEM21 EMerging News for the Latest Annual Meeting Information

SAEM EMerging News is your central, easyto-find repository for all the latest news and information you need for SAEM21. Look for it to arrive in your email in-box monthly to start and with more frequency as the annual meeting approaches. Check out the latest issue here.

SAEM RAMS The Newest RAMS Roadmaps Focus on Climate Change, Observation, Clinical Forensics A career in emergency medicine focused on climate change will give you the tools to advocate for patients and take steps to address the root causes of the problems they face from this global public health crisis. The recently added RAMS Roadmaps Climate Change provides resources and insider advice to help you succeed in climate change emergency medicine at every training level. If you’re interested in discovering the skills and knowledge needed to continued on Page 64

BRIEFS continued from Page 63 appropriately identify and provide active patient care beyond initial emergency department care, the recently-added RAMS Roadmaps Observation provides resources and insider advice to help you succeed in observation emergency medicine at every training level. Finally, the recently-added RAMS Roadmaps Clinical Forensics provides resources and insider advice to help those interested in exploring clinical forensics (the niche field of emergency medicine that addresses the result of criminal activities and the legal ramifications of those actions, including firearm-related injuries, knife and bluntobject related injuries, motor vehicle

collisions, sexual assault and abuse, child abuse, human trafficking, and domestic violence) succeed at every training level.

Three New RAMS Ask-a-Chair Podcasts

James Miner, MD, chief of emergency medicine at Hennepin County Medical Center and a professor of emergency medicine at the University of James Miner, MD Minnesota, discusses how he developed an interest in pain and sedation and how the current opiate epidemic has affected his research. He talks about the biggest challenges facing emergency medicine and how to turn these challenges into successes. Finally,

he gives advice to residents and young faculty on how to position themselves to rise into leadership as their career progresses. James Adams, MD, chair of the department of emergency medicine and professor of emergency medicine at Northwestern University, Feinberg James Adams, MD School of Medicine, talks about the administrative positions he’s held and how those positions prepared him for the role of chair and chief medical officer. He discusses what he looks for in a new faculty hire, his thoughts on quality metrics, and strategies for combatting burnout, among other things.

SAEM INTEREST GROUPS Academic Informatics

Interest Group Changes Name, Expands Scope Emergency medicine is increasingly becoming an information science. Within the last decade, advances in health information technology and widespread adoption of the electronic health record have transformed our practice and led to an explosion of data generated during the routine course of patient care. Largely in parallel, the practice of data science, an interdisciplinary field using machine-learning and other algorithmic techniques to gain insight into data, has increasingly become a part of research. These growing sources of data and innovative algorithmic approaches are now transforming how we view and approach clinical decision-making, health services planning, and public health initiatives. Recognizing this shift and the expanding role of data science in emergency health care and medicine at large, the SAEM Academic Informatics Interest Group announced a name change to the Informatics and Data Science Interest Group. In changing the name, it is the hope of the interest group to expand this community to those interested in these exciting new areas and to serve as a sounding board and intellectual hub to advance research and academic interests for medical students, residents, and faculty. In addition to monthly online meetings, ACEP and SAEM national meetings, and regular discussion on the SAEM community site, in the coming months the interest group hopes to offer a variety of services for the community including: • An emergency medicine informatics and data science citation network to facilitate research ideas and collaboration • Resources for those interested in getting started in data science and machine learning (how-tos, books, etc.) • A “Studio” format to present research ideas and challenges within our monthly meetings • Facilitated discussion on best practices in a variety of techniques that may be unfamiliar to many members such as unsupervised clustering and deep learning • A “Shop-talk” series on how informatics and data science activities are integrated into healthcare institutions and promote sustainable learning health care environments • Publication of white papers and concept papers • Yearly Resident and Faculty Awards for best papers in emergency medicine informatics and data science • Webinars offering advice on choosing whether an informatics fellowship is right for you To those who have contemplated getting into this field but have reservations or fears, please note that many of us started the same way with little background or knowledge. Fortunately, the informatics and data science communities are incredibly supportive and growing all the time. I often like to tell people who ask about getting into coding that “your first line of code for a project is just a Google click away.” Please consider joining us as we strive to transform emergency care and research!

Benjamin Sun, MD, MPP, Penn Medicine department of emergency medicine, talks about the role of EM physicians in the public policy realm and Benjamin Sun, MD, MPP how medical students and residents that have a special interest in this area can get more involved. He discusses how he developed a research interest in patient safety and quality and gives advice to medical students, residents, and even junior faculty looking to build a research career.

SAEM ACADEMIES Simulation Academy

Check Out What We’ve Been Up To! • Dr. Julie Gesch from Alameda Health was awarded the 2021 SAEM Simulation Research Grant for her work using in situ simulation to Dr. Julie Gesch improve stroke care. Congratulations Dr. Gesch! • In conjunction with the CORD simulation community, the SAEM Simulation Academy is excited to offer a simulation consulting service to help troubleshoot simulation education and curricular challenges. • The Emergency Medicine Resident Simulation Curriculum for Pediatrics (EM ReSCu Peds) is here and available for download. This free, open-access e-book contains sixteen cases to address critical pediatric topics for EM residents through simulation. • Four SAEM Simulation Academysponsored didactics have been accepted for the SAEM21 Virtual Annual Meeting and are included with your SAEM21 registration:

4. Can You See and Hear Me? Building a Training Program to Develop Association of American Medical Colleges Telemedicine Competencies (Simulation Academy and Telehealth Interest Group Sponsored) For more updates, including upcoming events, follow our Simulation Academy Twitter account @SAEMSimAcademy.

IN OTHER NEWS ABEM to Launch MyEMCert in Spring 2021

ABEM is introducing a new way to stay certified, designed with the uniqueness of Emergency Medicine in mind, and informed by the preferences of ABEMcertified physicians: MyEMCert. Core elements of MyEMCert include:

• Topic-specific modules that incorporate the “bread and butter” issues of emergency medicine

• Open-book modules that can be completed anywhere, anytime

• Immediate feedback providing scores, correct answers, and rationales

• Content that keeps you informed about key advances in the specialty

ABEM will move to a five-year certification period for physicians when they next recertify. By moving to a five-year certification period, physicians will be able to use MyEMCert to recertify starting in spring 2021. For more information, visit the webpage. If you have any questions, please contact ABEM at staycertified@ abem.org or 517.332.4800.

SAEM FOUNDATION Attention Academic EM Department Chairs! It’s time for the annual SAEMF Chairs’ Challenge. Each year, our AACEM Annual Retreat in March kicks off this important Challenge that raises vital funds to help strengthen the pipeline of EM researchers who will advance this specialty in the future. Browse our new SAEMF Donor Guide to learn about the Foundation’s impact, our researchers and the work they are doing, and how you can join your colleagues in supporting a bold vision for EM research. Donate today to join the Annual Alliance. In 2020, we raised $66,852 from 58 donors – this year we are setting our sights on 100% participation from our chairs. Please consider joining your fellow Chairs who have made the decision to show leadership in giving by becoming an Advocate Donor of the Annual Alliance. Why wait to donate until March? Your donation now counts towards the 2021 Challenge. Email Julie Wolfe at jwolfe@saem.org for more information about the SAEM Foundation Chairs Challenge.

1. Simulation for the Real World: How to Apply In Situ Simulation in Your Emergency Department (Simulation Academy Sponsored) 2. Interprofessional In Situ COVID-19 Preparedness Simulations: Program Implementation and Lessons Learned (Simulation Academy Sponsored) 3. Using Simulation for Transgender Medical Education in Emergency Medicine Residency (Simulation Academy and AWAEM Sponsored)

In 2020 the states on the left, highlighted in green, had 100% of their chairs participate in our Chairs' Challenge. In 2021 our goal, with your help, is to turn the entire map green!

ACADEMIC ANNOUNCEMENTS Dr. Elie Makes History as First Black Woman to be Named a Permanent Chair of an EM Department at a Major U.S. Medical School

Dr. Devjani Das Announced as the Clerkship Director and promoted to Associate Professor of Emergency Medicine at Columbia University

Marie-Carmelle Elie, MD, has been named chair of the department of emergency medicine at the University of Alabama at Birmingham School of Medicine. She is the first Black woman to be named a full professor and permanent chair of an academic emergency medicine department Dr. Marie-Carmelle Elie at a major U.S. medical school. Dr. Elie is currently an associate professor in the division of critical care, department of emergency medicine and the division of palliative care, department of medicine at the University of Florida’s College of Medicine. She will officially assume the role of chair on June 1, 2021.

Devjani Das, MD, was promoted to associate professor of emergency medicine at Columbia University Vagelos College of Physicians and Surgeons. Dr. Das is currently the director of undergraduate point-of-care ultrasound education. She was announced as the director of a new emergency medicine Dr. Devjani Das clerkship at Columbia University. She is the current president of SAEM’s Academy for Women in Academic Emergency Medicine (AWAEM).

Dr. Nikhil Goyal Appointed to BOD for the National Resident Matching Program

Dr. Tiffany Murano Announced as the Vice Chair of Education for Columbia University Department of Emergency Medicine

Dr. Tiffany Murano

Tiffany Murano, MD, professor of emergency medicine at Columbia University Vagelos College of Physicians and Surgeons will be vice chair of education for Columbia University department of emergency medicine effective February 1, 2021. Dr. Murano is the president-elect of the Council of Council of Emergency Medicine Residency Directors (CORD).

Dr. Liliya Abrukin Announced as the Director of Quality and Patient Safety for Columbia University Department of Emergency Medicine

Dr. Liliya Abrukin

Liliya Abrukin, MD, an assistant professor of emergency medicine at Columbia University Vagelos College of Physicians and Surgeons has been announced as the director of quality and patient safety for Columbia University department of emergency medicine effective January 1, 2021.

Dr. Nicholas Gavin Promoted to Associate Professor of Emergency Medicine at Columbia University

Dr. Nicholas Gavin

Nicholas Gavin, MD, MBA, MS, was promoted to associate professor of emergency medicine at Columbia University Vagelos College of Physicians and Surgeons. Dr. Gavin is the vice chair of operations of the department of emergency medicine at Columbia University.

Dr. Nikhil Goyal

Nikhil Goyal, MD has been appointed to the board of directors for the National Resident Matching Program for a four-year term starting in July 2021. Dr. Goyal is director of medical education/DIO (Wyandotte) and senior staff physician in the departments of emergency medicine and internal medicine at Henry Ford Health System in Detroit, Michigan.

Dr. Ian Martin Appointed to the MCW Consortium on Public and Community Health Ian B.K. Martin, MD, MBA has been appointed by the Advancing a Healthier Wisconsin Endowment (AHW) to its public oversight body, the MCW Consortium on Public and Community Health (Consortium). The Consortium provides oversight to AHW’s mission to improve health and advance health Dr. Ian B.K. Martin equity by supporting innovative and impactful work statewide. Dr. Martin is system chair of the department of emergency medicine and professor with tenure of emergency medicine and medicine at the Medical College of Wisconsin (MCW) School of Medicine. He is also emergency physician-inchief at the Froedtert and MCW Health Network. Dr. Martin is the immediate past-president of SAEM.

Dr. Taher Vohra Appointed Vice Chair of Education at Henry Ford Health System Taher Vohra, MD, has been appointed vice chair of education in the department of emergency medicine at the Henry Ford Health System. In his new role, he will oversee the educational mission of the department inclusive of all medical student, resident, and fellowship training programs. He will also Dr. Taher Vohra continue to serve as program director for the emergency medicine residency at Henry Ford Hospital.

Dr. Sharon Chekijian Receives Fulbright U.S. Scholar Award to Republic of Armenia for Emergency Systems and Curricular Development Sharon Anoush Chekijian, MD, MPH, has received a J. William Fulbright U.S. Scholar Program award for her work in emergency systems and curricular development in the Republic of Armenia. Dr. Chekijian will base her work, conduct research and lecture at the School of Dr. Sharon Anoush Chekijian Public Health at the American University of Armenia (AUA), as part of a project to establish a postgraduate program in emergency medicine, to expand and develop emergency services, and to perform research capacity building in emergency services provision and evaluation. Dr. Chekijian is an assistant professor in the department of emergency medicine at Yale Medicine. She is faculty member in the section of global health and international emergency medicine as well as in the section of administration.

Jill Zaheer Retires as System Vice Chair of Emergency Medicine for Administration and Finance at Icahn School of Medicine at Mount Sinai Jill Zaheer, MPH has retired as the system vice chair of emergency medicine for administration and finance at Icahn School of Medicine at Mount Sinai, effective December 31, 2020. Ms. Zaheer is a senior executive leader with more than 30 years of outstanding financial Jill Zaheer achievements in academic health center administration and was part of the administrative team who created the department of emergency medicine at the Icahn School of Medicine at Mount Sinai in 1994. She is one of the co-founding members of SAEM’s Academy of Administrators in Academic Emergency Medicine (AAAEM).

Dr. Wallace A. Carter Appointed Full Professor of Clinical Emergency Medicine at Weill Cornell Wallace A. Carter, MD, has been appointed full professor of clinical emergency medicine at Weill Cornell. He is also vice chair of clinical and faculty affairs in the department of emergency medicine. He currently leads operational, patient experience and Dr. Wallace A. Carter quality improvement initiatives within the department of emergency medicine; collaborates with ED nursing leadership, physicians and advanced practice providers to ensure the delivery of highquality emergency care; and oversees all faculty compliance for the department.

Uganda Graduates First EM Residents Randall Ellis, MD, MPH, MBA, faculty of Mbarara University of Science and Technology (MUST), announced that in October 2020, MUST graduated five emergency medicine residents — the first emergency medicine residents for the entire country of Uganda. The five residency graduates will be mentored as faculty to lead the residency forward.

SUBMIT YOUR ANNOUNCEMENT! The SAEM Pulse Academic Announcements section publishes academic appointments, promotions, retirements, grant awards, research announcements, published papers, etc. Send your content (50-75 words max) to newsletter@saem.org. The next content deadline is April 1, 2021 for the May/June 2021 issue. 67

NOW HIRING POST YOUR OPEN JOBS IN FRONT OF OUR QUALIFIED CANDIDATES! Accepting ads for our “Now Hiring” section! Deadline for the next issue of SAEM Pulse is April 1. For specs and pricing, visit the SAEM Pulse advertising webpage.

EM Jobs Now on SAEM Facebook Does your institution have an open position it’s looking to fill? Contact John Landry at 847-257-7224 or jlandry@saem.org to add your name to the career widget on our SAEM Facebook page. Job seekers: Click on “Careers” on the left-hand menu of SAEM’s Facebook page to view recently posted jobs in academic emergency medicine.

Free CV Critique Did you know that EM Job Link offers a free CV critique service to job seekers? As a job seeker, you have the option to request a CV evaluation from a writing expert. You can participate in this feature through the CV Management section of your account. Within 48 hours of opt-in, you will receive an evaluation outlining your strengths, weaknesses and suggestions to ensure you have the best chance of landing an interview.

Job Alert! Are you looking for a job in academic emergency medicine? Create a personal job alert on EM Job Link so that new jobs matching your search criteria will be emailed directly to you. Make sure the perfect opportunity doesn’t pass you by. Sign up for job alerts today on EM Job Link by clicking on Job Seekers and then selecting Job Alerts. You will be notified as soon as the job you’re looking for is posted.

NEW CAREER OPPORTUNITIES IN ACADEMIC MEDICINE We’re focused on shaping the future of emergency medicine and we need strong Academic Physicians to lead-the-way. Join the team at one of our academic medical centers across the nation and create your ideal program from the ground-up!

Join our team

teamhealth.com/join or call 877.650.1218

Featured Positions Associate Program Director Osceola Regional Medical Center Kissimmee, Florida

Core Faculty Toxicology Fellow Brandon Regional Hospital Tampa Bay, Florida

833.619.0378 EVPS.com/SAEM

Exciting opportunities at our growing organization • • • •

Emergency Medicine Faculty Positions Pediatric Emergency Medicine Faculty Positions Vice Chair, Clinical Operations Vice Chair, Research

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

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

FOR MORE INFORMATION PLEASE CONTACT:

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

Baylor College of Medicine (www.bcm.edu) is recognized as one of the nation’s premier academic health science centers and is known for excellence in education, research, healthcare and community service. Located in the heart of the world's largest medical center (Texas Medical Center), Baylor is affiliated with multiple educational, healthcare and research affiliates (Baylor Affiliates). The Henry JN Taub Department of Emergency Medicine at Baylor College of Medicine seeks a Vice Chair of Research to oversee research operations for the department. The responsibilities of this position shall include: 1. Maintain a highly productive research operation with a national and international reputation. 2. Assist the Chair of the Department of Emergency Medicine in developing/recruiting/retaining high potential research faculty. 3. Provide guidance and mentorship to junior faculty members in defining and developing their research projects and directions. 4. Support and expand resident, fellow, graduate student, medical student and undergraduate involvement in research, presentations, and publications. Potential for development of a training grant for resident/fellow research. 5. Compete successfully for external funding in order to maintain a well-rounded research portfolio. 6. Provide oversite, guidance and annual evaluations to research associated faculty members. 7. Have regular meetings with the research manager for financial updates on all research portfolios within the Department. Make recommendations to the Chair for corrective actions needed to keep the research operation viable and solvent. Salary, rank, and tenure status are contingent upon candidate qualifications. The rank and tenure status awarded will be based upon qualifications in alignment with Baylor College of Medicine's promotion and tenure policy. Qualified applicants are expected to have a research record with significant extramural funding and leadership skills to develop a strong multidisciplinary collaborative Emergency Medicine research program and continue to grow current departmental research efforts. In addition to the above responsibilities, other duties may be assigned by the Chair.

Please include a cover letter and current curriculum vitae to your application. This position is open until filled. For more information about the position, please contact Dick Kuo, MD via email [dckuo@bcm.edu]. MINIMUM REQUIREMENTS Education: M.D. degree or equivalent Experience: Research Fellowship not required for application Licensure: Must be currently boarded in Emergency Medicine and eligible for liscensure in state of Texas.

THANK YOU To our brave and dedicated emergency physicians, nurses, and other medical staff who are on the front lines answering the call to care for the most vulnerable in our society during this time of great need.

SAEM Pulse March-April 2021

Articles inside

Academic Announcements

Briefs and Bullet Points

Human Trafficking: Identifying and Treating Victims

A View of Infinity

Five Tips to Transform Medical Students and Residents into Self-Directed Learners

EM Physician Scientist Training Programs: Opportunities for Residents Committed to Careers in EM Research

Why It’s Important for My Patients to Know I’m a Doctor

Why Should I Be Involved in RAMS? Reflections from the 2020-2021 RAMS Board

A Picture Is Worth a Thousand Words: Utilizing Smartphone Technology in the Evaluation of ENT Emergencies

Advice for Contract Negotiations from a Health Care Administrator Turned Physician - Part 2

Expressing Gratitude to the 2021 Annual Alliance and Legacy Society Donors