Newsletter Volume XVI March 2015

Volume XVI March 2015

California Chapter of the American Academy of Emergency Medicine

NEWSLETTER Twitter @CALAAEM and www.Facebook.com/CALAAEM Open Access at www.calaaem.org

PRESIDENT’S MESSAGE March 2015

INSIDE: 5

Education, Mentorship,

and Adventure at UC

Irvine EMIG

Sims Cisneros 6 The Heart of Your

Insurance Program Borgia 7 WestJEM Plaque Presentation Langdorf

L

Trusted Advocacy for Fairness and Due ProcessTM - “What’s in your wallet?”

ate one evening in 1974 before beginning an ED night shift moonlighting at William A. Foote Memorial Hospital, 45 miles west of my residency training ground in Ann Arbor at University of Michigan, I decided to check my mailbox in the ED break room. I was looking for the latest version of the ED schedule (remember, this was long before the Internet), but what I found was an envelop containing a membership card to the American College of Emergency Physicians. ACEP was a fledgling organization that arose in East Lansing, 30 miles straight north of Foote, in support of the nascent specialty of Emergency Medicine. The ED group at Foote, in close contact with ACEP’s nearby headquarters and eager to support the new organization, had paid my membership dues.

As I placed the ACEP card in my wallet, could I possibly have imagined that decades later in California, I would have lengthy and detailed conversations about the beginning of ACEP with the niece of one of ACEP’s East Lansing founders? Even more improbable, could I have guessed I’d be writing this editorial, four decades later, on the critical issues of Practice Fairness and Due Process— largely ignored, practically and historically speaking, by ACEP, but a part of the

heart of AAEM? Answer to both questions: never in a million years.

Fast-forward 41 years to January 22, 2015, and a conversation I had with one of the regional directors of CEPAmerica, now reportedly providing care for over 25% of all the ED visits in California.1 This RD I spoke with is familiar with Good Samaritan Hospital in San Jose. “Good Sam,” owned by Hospital Corporation of America (NYSE symbol: HCA), is one of HCA’s flagship facilities in California, enjoying an excellent payor mix and serving the area around Los Gatos, a tony bedroom community at the southwestern end of Silicon Valley. CEP-A has held the ED contract at Good Sam for over 20 years. The following background information on Good Sam and HCA is critical to understanding the gist of the dialogue I had with the RD. EmCare, now a large division of Envision Healthcare as a part of the Envision IPO in August, 2013, is engaged in what AAEM believes is a fee-splitting arrangement, which raises concerns over violation of federal fee-splitting laws.2 During a lecture at AAEM’s 2014 Scientific Assembly in New York, CEP-A’s CEO, Wesley Curry, presented several case studies of ED con-

Christensen

President’s Message

tracts CEP-A had lost to EmCare and TeamHealth, before the birth of Envision. I have carefully read the voluminous analyses by the multiple investment banks that advised clients on the Envision IPO. Those complex documents mention the joint venture between EmCare and HCA—a new arrangement that could place CEP-A’s contract at Good Sam at even greater risk of turnover to EmCare. Perhaps even more concerning when linked to the joint venture, those same investment banking notes refer to “cross selling of multiple service lines” as part EmCare’s strategy.

Put simply, it appears that EmCare is not only poised to offer HCA “anesthesiology, hospitalist, surgery and radiology” specialty services, but is willing to form a joint venture with HCA in which physician-generated fees are split with HCA. Surgeons, take note here: EmCare could now have you in its crosshairs.

AAEM is strongly opposed to the joint venture practice, and believes it may violate state and federal laws that prohibit fee-splitting arrangements over which working physicians have no control. ACEP, whose list of former presidents includes the founders of both EmCare and TeamHealth, has thus far failed to join AAEM in formal support of the thousands of physicians potentially harmed by the spread of hospital staffing company joint ventures and the possible fee-splitting they may hide. It is important to note that AAEM is advocating at a federal level for billing transparency. AAEM has long held that every emergency physician should know exactly what is billed in his/her name. Such transparency could aid physicians in ultimately understanding the line-item details of the management fees they incur.

Good Sam’s anesthesiologists have recently merged their practice with California Emergency PhysiciansAmerica,3 apparently hoping to avoid facing the prospect of either working for EmCare or leaving Silicon Valley in search of better employment opportunities. A newly minted CEP-A anesthesiologist recently wrote on CEPA’s website: “So why did we choose to join an integrated acute care practice in which specialties such as emergency and hospital medicine could easily overshadow our own?

One simple reason: external market forces threatened our practice model.”3 I believe the Good Sam anesthesiologists understand the significant temptation for HCA to award all the hospital-based physician contracts at Good Sam to EmCare, in exchange for the new revenue stream from a joint venture. Have those CEP-A anesthesiologists done an opportunity cost analysis of the value of future cash flows to EmCare-HCA in a joint venture?6 Do the anesthesiologists know what a monopsony is, especially in relation to the prisoner’s dilemma in game theory?12 And most importantly, do they understand how to break the prisoner’s dilemma and restore physician autonomy and medical CAL/AAEM Newsletter

professionalism in the interest of better patient care?12 No easy questions here, but the answers are critical to ensuring fairness and due process.

A cascade of contract turnovers could create an enormous cash cow that could line the pockets of HCA and EmCare senior managers and Envision Health investors alike. Are the anesthesiologists in CEP-A prepared to split fees directly with HCA, eliminating EmCare as the “middleman,” in order to retain their exclusive service contract at Good Sam? These complex questions go to the heart of fair market value, and again, AAEM has a long record of decrying fee-splitting arrangements such as those between HCA and EmCare, euphemistically spun as a “joint venture.” 4 Now, back to that conversation with the CEP-A regional director. I asked him whether CEP-A had worked out a revenue division arrangement between the emergency physicians and their new anesthesiologist partners at Good Sam. The RD turned my question around and asked me, “Are you worried about revenue sharing?” “I’m worried about fairness in the development of any revenuesharing process,” I replied, noting that I had spent over 15 years studying the fair market value of management services in EM and had completed a 600-page draft toolkit for AAEM to inform members on the complex subject of practice fairness in our specialty. Developing a revenuesharing model equitably would require starting with a definition of fairness, I pointed out. The RD’s response was at once revealing and alarming: “Different people think different things are fair.”

Three years earlier I had asked a high level CEP-A officer for his definition of fairness, in the context of the complexity of healthcare reform as it might affect emergency medicine. “I don’t like that word, I don’t know what that word means—it means different things to different people,” he replied. Is there a pattern here at the top of CEP-A, with respect to lack of understanding of fair market value and fair process? Are CEP-A’s rank-and-file physicians, who generate the income stream that pays the senior management, fully aware of the fair market value of management services and potential interest conflicts inherent in the CEP-A voting structure? More tough questions here for the EM group that touts itself for seeing over 25% of all the ED patients in the state of California and is bent on further expansion.

As a part of an important learning process, I hope the CEP-A RD and the CEP-A officer who appointed the RD as a part of an upper management circle in CEP-A—and every hospital-based physician will consider the following: Fair Market Value Standards: Clear evidence that fairness, and its corollary, fair market value, matters in Emergency Medicine and other hospital based specialties—just 2

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President’s Message

as it matters everywhere else.

our nation’s emergency departments—that the Department of Labor, acting through the Pension and Welfare Benefits Administration (PWBA), issued Proposed Regulations Relating to the Definition of Adequate Consideration (53 Federal Register 17632). Here “adequate consideration… means the fair market value of the asset as determined in good faith by the trustee or named fiduciary [italics added] involved in the management of pension and welfare benefits serving the public good.” This complex proposal process stipulates that value determinations “require a fiduciary to apply sound business principles of evaluation and conduct a prudent investigation of the circumstances at the time of the valuation.” Furthermore, the PWBA proposed that “the fiduciary making the valuation must itself be independent of all the parties of the transaction… or rely on the report of an appraiser who is independent of all the parties to the transaction…” These proposed requirements in summary defined action in “good faith” by the fiduciary. Though the PWBA subsequently withdrew its complex proposal after seven years of public commentary, to this day the proposal still widely informs the community of business valuation analysts and highlights the public merit of a transparent valuation process. 7 In Setting Limits Fairly: Learning to Share Resources for Health, authors Norman Daniels and James Sabin bring forth the concept of “accountability for reasonableness” as an adaptable means “to a answer a central question about justice and health care: how can a society or a health plan meet population health needs fairly under resource limitations?”10 The authors cite that “the following four conditions make more precise the notion for accountability for reasonableness: 1. Publicity Condition: Decisions…must be publicly accessible [Editor’s note: this is the FMV transparency requirement.]

2. Relevance Condition: The rationales…should aim to provide a reasonable explanation [regarding] how the organization seeks to provide “value for money” in meeting the varied needs of a defined population…

[Editor’s Note: this is one side of the valuation argument.]

3. Revision and Appeals Condition: There must be mechanisms for challenge and dispute resolution regarding…decisions, and more broadly, opportunities for revision and improvement of policies in light of new evidence or arguments. [Editor’s Note: this is in effect the other side of the valuation argument] 4. Regulative Condition: There is voluntary or public regulation of the process to ensure that conditions 1-3 are met. [Editor’s Note: this in essence ensures that a “win-win” outcome occurs and is analogous to either party being able to walk away until a mutually

Multiple public policies underscore the importance of fair market value (FMV) concepts and standards, and a broad consensus of Business Valuation Standards has at its nucleus a formal definition of the FMV of property, including intangible assets—which are clearly the central issue in any financial appraisal of hospital-based physician group operations, including revenue sharing and management services.5, 6 The following standards are used nationally as fundamental methods for FMV determinations; AAEM believes that application of these standards in assessing hospital-based physician business entities is long overdue. 7 IRS Revenue Rulings are issued to provide interpretive regulations that add operational substance to the tax laws passed by Congress. Revenue Ruling 59-60, widely cited by the courts and in the appraisal community since its publication in 1959, defines FMV as “the price at which property [including intangibles] would change hands between a willing buyer and a willing seller when the former is not under any compulsion to buy, and the latter is not under any compulsion to sell, both parties having reasonable knowledge of the common facts.” [italics added]. 8 Thus, no transaction or process is fair without common knowledge, which game theorists define as “I know that you know that I know that you know…” every relevant fact about the transaction. Any tampering with this pure “hall of mirrors” common knowledge process shared by the two negotiating parties is the point at which the process becomes corrupt, and the “fair” disappears from fair market value. AAEM believes the history of EM is rife with wholesale manipulation of the information relevant to the details of the cash flows at the financial heart of EM business arrangements. 9 As information is withheld, often in ways both subtle and intimidating, AAEM believes that arrangements, including pyramid growth buy-sell agreements based on lop-sided organizational voting structures, discriminate against the young physicians at the bottom of the pyramid. With limited choice in a marketplace often dominated by those in the inner circle of large management groups, AAEM believes that EPs exploited by financial arrangements lose the fair practice environment that is vital to the delivery of the highest quality emergency care—and ultimately patient care may suffer.

So critical is the concept of fair market value to the public policy surrounding pension and welfare payments, both clearly vital societal safety net provisions—not unlike Volume XVI March 2015

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President’s Message

acceptable arrangement is reached—thus avoiding “win-lose,” “lose-win” and “lose-lose” outcomes.]”

Just as these authors note, “There is no escaping the need to construct a fair process for setting limits to health care,” so can one argue that fairness matters in all aspects of health care resource allocation—including management costs in the practice of emergency medicine and other hospital-based specialties, and the development of complex revenue sharing arrangements.

In summary, the universal themes in fair market valuation standards and fairness-based processes are 1) common knowledge, which is synonymous with the more popular term transparency, and 2) lack of compulsion, the option of either party to walk away until mutually favorable terms are reached. Until AAEM adopted the role of The Trusted Advocate of Fairness in Emergency MedicineTM, the EM community had never had an entity committed to acting in good faith to promote transparency and lack of compulsory acceptance of win-lose terms in the countless negotiations that define the business of EM. Any medical specialty organization committed to advocating for fairness and acting as an agent on behalf of its members, 11 can adopt the standards cited above.

So, to physicians concerned about their loss of autonomy and medical professionalism to what AAEM believes may be a potentially illegal fee-splitting arrangement thinly disguised as a “joint venture,” consider actor Samuel L. Jackson’s pressing question on the advantages of the Capital One credit card: “What’s in your wallet?” What medical professional organization has been on the record for over 20 years consistently opposing any and all arrangements and processes that are not rigorously fair? Moreover, what professional organization is currently championing due process at a federal level, advocating that due process—a basic 5th Amendment right—be made a provision for Conditions of Participation in the federally sponsored Medicare program? The answer is unequivocal: The American Academy of Emergency Medicine.

CEP-A’s Jay Kaplan is in line for the president’s gavel at ACEP. In regard to the fundamental issues of Practice Fairness and Due Process,12 I wait with great interest to see how years in CEP-A’s inner circle may affect Dr. Kaplan’s upcoming presidency, and whether he can influence ACEP to reach across the aisle and join AAEM in supporting the thousands of hospital-based physicians potentially hurt by fee-splitting and other joint venture arrangements. Now that a Florida emergency physician has filed a suit against HCA, EmCare and EM-1 Medical Services alleging wrongful termination after she questioned a corporate decision to limit ED staffing during a period of serious ED crowding, resulting in a risk to patient safety, support for fair and equitable practice environments is no longer an abstract issue.13 This case also raises concern about potential violation of statutes that ban the corporate practice of medicine.14 AAEM and ACEP united in formal support of practice fairness and due process rights CAL/AAEM Newsletter

would represent a landmark step in protecting emergency physicians and their patients. I believe such united support is long overdue and would be welcomed everywhere.

By the way, I still have both membership cards in my wallet. How about you?

Respectfully submitted, John B. Christensen, MD, FAAEM Cal/AAEM President AAEM Director at Large Chairman, AAEM Practice Fairness Council Editor, The AAEM Practice Fairness ToolkitTM ACEP Life Member AAEM: The Trusted Advocate of Fairness in Emergency MedicineTM REFERENCES 1.

See CEP-A advertisements in The Western Journal of Emergency

3.

www.cepamerica.com/news-resources/perspectives-on-the-acute-

4.

http://www.aaem.org/em-resources/critical-em-practice-issues/

2.

5.

6.

7.

8.

9.

Medicine. http://www.aaem.org/UserFiles/MayJune14PresidentsMessage.pdf care-continuum/2015-january/anesthesia’s-role-in-the-acute-carecontinuum corporate-practice Robert F. Reilly and Robert P. Schweihs, Valuing Intangible Assets (New York: McGraw-Hill, 1999) Douglas Hubbard, How to Measure Anything: Finding the Value of “Intangibles” in Business (New Jersey: John Wiley & Sons, 2010) Shannon Pratt, Valuing a Business: The Analysis and Appraisal of Closely Held Companies (New York: McGraw-Hill, 2008) The Mercer Capital Staff, Revenue Ruling 59-60 at 50: Rediscover Fair Market Value (Memphis: Peabody Publishing, 2009) Ian Molho, The Economics of Information: Lying and Cheating in Markets and Organizations (Oxford: Blackwell Publishers, 1997)

10. Norman Daniels and James Sabin, Setting Limits Fairly: Learning to Share Resources for Health, 2nd Edition (Oxford: Oxford University Press, 2008)

11. Robert Pindyck and Daniel Rubinfeld, “The Principal-Agent

Problem,” Microeconomics, 7th Edition (New Jersey: Prentice-Hall, 2009), 630-633.

12. http://www.aaem.org/UserFiles/TrustedAdvocateofFairnessToC.pdf 13. http://www.tampabay.com/news/health/doctor-says-she-was-firedfor-reporting-low-staffing-at-brandon-regional/2218497

14. http://www.calaaem.org/UserFiles/PresidentsMessageNovember20 14.pdf

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Volume XVI March 2015

Medical Student Section

Education, Mentorship, and Adventure at UC Irvine EMIG Lauren Sims, MSIII Victor Cisneros, MSIII

EMIG Presidents 2014-2015, UC Irvine Health School of Medicine

The Emergency Medicine Interest Group (EMIG) at the University of California, Irvine has had a productive year thus far. We have continued the tradition of both promoting the specialty of emergency medicine throughout the study body while simultaneously preparing emergency medicine-bound students for a successful residency application and career. Our executive board has worked hard to return events that have worked well in the past, as well as introduce new and exciting activities to the mix.

In November, first- and second-year medical students participated in our annual Emergency Medicine Procedures Workshop. They were able to practice skills such as obtaining IV access and placing foley catheters. Senior medical students, residents and faculty were present to instruct at the various stations. It was a great event for students to begin obtaining clinical skills while taking a break from their rigorous academic work. In December, we held our second annual Emergency Medicine Research Meeting. Students interested in participating in emergency medicine research were able to hear our faculty members present on their research interests and current projects. The event served to connect students with faculty members and fostered ideas for new projects.

Our Wilderness Medicine Interest Group (WMIG) coordinated a camping trip to Joshua Tree with the WMIG from the Keck School of Medicine at USC. They practiced their wilderness survival skills while partaking in outdoor activities like rock climbing. Through the Disaster Medicine Interest Group (DMIG), students were able to take part in the Emergency Medical Services (EMS) Agency’s statewide medical and health exercise. They witnessed first hand the behind the scenes execution of a disaster drill.

Mentorship continues to be a strong point of our interest group both among student colleagues and faculty. Emergency medicine faculty members have been graciously hosting our Talk Shop Dinners in their homes where they can more intimately mentor a small group of emergency medicineinterested students. Our senior advisors also have put together an excellent instructional video to help third-year medical students prepare for away rotations and the application process.

We still have more exciting events planned for the remainder of the academic year. As the 2014-2015 UCI EMIG Executive Board co-presidents we welcome your comments, suggestions and interest in getting involved. Please feel free to contact us through our website: uciemig.com.

Board Members of the California Chapter of the American Academy of Emergency Medicine 2014-2015 Board Members Deena Bengiamin, MD Reena Duseja, MD, MS John Grady, DO, FAAEM Joanne Williams, MD, FAAEM Resident Representatives Erica Frumin, MD

President John Christensen, MD, FAAEM Vice President Jennifer Kanapicki Comer, MD, FAAEM Immediate Past President Lisa Mills, MD, MPH, FAAEM

Secretary Randy Woo, MD

Past Presidents Trevor Mills, MD, MPH, FAAEM Steven Gabaeff, MD, FAAEM Shahram Lotfipour, MD, MPH, FAAEM Brian Potts, MD, MBA, FAAEM Robert Rodriguez, MD, FAAEM Stuart Swadron, MD, FAAEM Francine Vogler, MD Treasurer Shahram Lotfipour, MD, MPH, FAAEM

CAL/AAEM Contact AAEM Liaison: Emily DeVillers, 555 East Wells St., Suite 1100, Milwaukee, WI 53202, www.calaaem.org, (800) 884-2236

Statements expressed in this journal are those of the authors and do not necessarily reflect those of the editors, the editorial board, the American Academy of Emergency Medicine, or the Division for the California Chapter of AAEM. This article is intended for the individual use of AAEM members.

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The Heart of Your Insurance Program Andy G. Borgia, CLU

Disability insurance is truly the heart of any personal insurance portfolio, especially for Emergency Physicians.

Not only is it the only type of insurance that pays you, but it is also the most important type of insurance you need. Statistically, just over one in four people under age 30 will become disabled before they retire,1 with an astonishing 59% of new disability claims approved in 2013 for individuals age 50 or older with the average age of disability just over age 50.1 Sickness is responsible for over 90% of disabilities.2 Back pain, degenerative disks, arthritis, osteoporosis and rheumatism are among the most frequent ailments, followed by mental disorders, circulatory system disorders, cancers and tumors; and nervous system and sense organ disorders.2 Emergency Medicine is a mentally and physically demanding specialty. Based on the above probability statistics, the fact that an average disability claim lasts almost three years,2 and that one in eight workers will be disabled for five years or more during their working careers,6 it is vitally important for all Emergency Physicians to protect themselves in the event they become disabled and cannot practice Emergency Medicine.

There are three types of disability insurance policies: Association, Group and Individual. Association and Group disability policies are only available from the entity covered, e.g. your employer. These contracts are between the entity and the insurance company. As a result you as an individual have little, if any, control over contractual provisions, premiums, and whether the policy remains in effect at all.

The definition of disability is not specialty-specific for the entire benefit period. These policies are designed as supplements to individual coverage.

An individual policy is a contract between you and the insurance company, so you are in control. Policy premiums and contractual provisions are guaranteed and will not be changed, nor will the policy be cancelled, if the policy is specified as non-cancellable and guaranteed renewable.

Insist on this with any individual disability plan. Monthly benefits offered are generally 50 – 60% of income, up to a maximum benefit of $25,000 per month.

Just as your heart has four chambers, there are four forms of disability that an Emergency Physician needs to protect against, and should be included in your individual policy. And just as if one of the heart’s chambers is not working properly, if one of the risks of disability is not adequately provided for, early detection (before a disability CAL/AAEM Newsletter

occurs) is key. Seek a dedicated insurance broker, defined as an independent professional representing a number of companies, who is well-versed with contractual provisions and is highly experienced in advising physicians. A specialist, not a generalist, is optimum – again, similar to medicine.

Now back to the four forms of disability: Total, Partial/Residual, Recovery, and Presumptive. You need to be protected and compensated by your policy if you are totally disabled and unable to practice “the material and substantial duties” of your “medical specialty.” ONLY a select few individual policies provide this comprehensive protection. Don’t be fooled by individual or group policies that only mention occupation. In these types of policies your occupation is “physician.” If you cannot practice Emergency Medicine but are able to practice urgent care medicine or perform some other job (in or outside of medicine) you will not be considered totally disabled. The policy you purchase should provide that you receive the total disability benefit when you cannot practice Emergency Medicine specifically.

Other limited provisions in a number of individual plans, and virtually all Association and Employer Group Plans, are phrases such as “any and every duty,” “completely,” “all,” “complete inability,” and so on.

Partial/Residual Benefits are paid if you are unable to practice Emergency Medicine on a full-time basis, e.g. the same number of shifts as prior to your disability, cannot do all duties, etc. After a specified waiting period (usually 90 days), the more comprehensive individual policies will pay 100% of your total disability benefit for the first 6 – 12 months of partial disability, and a lesser percentage thereafter. For example, if you earn 50% of your normal pay practicing Emergency Medicine part-time you will receive 50% of your disability benefit. The majority of total disabilities at some point are partial disabilities. So this is a very critical provision. Also, most Emergency Physicians will return to work on a part-time basis before they become full-time again, so you need to be compensated during that transition.

The next step after a partial disability is recovery. As every Emergency Physician is aware, payment for today’s shift may not be received for one to two months. A policy Recovery Benefit will pay a percentage of your predisability earnings, similar to the Partial Benefit. After your income exceeds 80 – 85% of your pay prior to disability, you are then no longer considered disabled.

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Presumptive Total Disability is severe and occurs when you lose the use of both hands or both feet, one of each, sight, speech or hearing. You are presumed disabled whether you can perform Emergency Medicine or not – though it is highly unlikely that you would be able to practice in such circumstances. Individual policies will pay Presumptive Benefits equal to the total disability benefit for the entire benefit period, for life in some instances.

Since individual disability insurance premiums are based on age, it is prudent to establish coverage early in your career. If you already have coverage it is advantageous to review your contracts based on new provisions and coverage limits. Remember, your ability to practice Emergency Medicine is your most important asset. Make sure it is protected. Seek the advice of a professional insurance broker who specializes in disability insurance for physicians.

provided by him and the sources he cited. He is not affiliated with WestJEM, and the opinions expressed are his alone.

He can be reached at andyb@DI4MDS.com, 858-523-7572 or www.DI4MDS.com

REFERENCES 1. U.S. Social Security Administration, Fact Sheet February 7, 2013 2. Council for Disability Awareness, Long-Term Disability Claims Review, 2014 3. Council for Disability Awareness, Long-Term Disability Claims Review, 2014 4. Council for Disability Awareness, Long-Term Disability Claims Review, 2014 5. Gen Re, U.S. Individual DI Risk Management Survey 2011, based on claims closed in 2010

Disclaimer: This article is by Andy G. Borgia, CLU, who has been advising physicians on their disability insurance needs for over 20 years. The information contained in the article was

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6. Commissioner’s Disability Insurance Tables A and C, assuming equal weights by gender and occupation class

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WestJEM Section WestJEM Plaque Presentation to Dr. Christensen Mark Langdorf, MD, MHPE, FAAEM

WestJEM Editor-in-Chief

The Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health (WestJEM) was proud to present a plaque to Cal/AAEM President Dr. John Christensen at the AAEM Assembly in Austin this month. We sincerely appreciate Cal/AAEM’s long time support and sponsorship of the journal which allows us to foster worldwide dissemination of science and best practices in emergency medicine and public health.

We will house the plaque for Cal/AAEM at UC Irvine Department of Emergency Medicine Academic Offices and as the Publisher of WestJEM. Sincerely, Mark Langdorf, MD, MHPE Editor-in-Chief

Plaque presentation to Dr. Christensen at the AAEM Assembly in Austin.

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