Friday, July 13, 2007

Advocacy, Leadership and Legislation

May 2008

USAEM, AEP, AAPS, AAFP, and the ACEP certification section are working hard to unify forces on behalf of the Legacy Emergency Physicians.

On May 18-21, 2008 members of all organizations are getting together in Washington, D.C. to join forces and begin to work with each other.

At the same time there is a previously scheduled ACEP legislative meeting and registration is FREE to ACEP members. The registration fee for non-ACEP members is $370.00. Attendance at the ACEP meeting is not required, but is recommended to get the most out of the event.
Hospitality events will be arranged at the Omni Shoreham Hotel.

For those who cant make this meeting, the next major get together of all members will be in Jacksonville, FL in October 2008 hosted by AEP and USAEM. At each conference remember to look for events that include members of the other organizations.

Saturday, June 30, 2007

$25 a year for national representation and professional membership?

Maryn McKenna's recent article in Annals of Emergency Medicine, really sums up what is happening to re-shape the paradigm on who should be practising emergency medicine. Please read it and then decide whether you should be part of any organization, or if you are, whether that organization is truly representative of you.

Which organization should you join? Should you even join any? There are some questions worth asking.

Does an emergency physician who has been practising for over 20 years, but who, by some twist of dates was denied eligibility to take his ABEM, deserve to lose his job?

Do emergency physicians work solo, or are we in a TEAM with emergency nurses and paramedics?

Does experience count for anything? Is it better to be treated by a family physician or internist, who's been putting in chest tubes and handling arrests and trauma for decades, or a new EM residency graduate, who has been 'doing it' for a year or so? Who would you want treating your family members?

With challenges in America over the issue of access to emergency care, do we need better and fairer recognition of emergency physicians or do we need to make the tent smaller, and thus deny care to even more of the 60 million uninsured American citizens?

Think about these questions.

Then think about why you even want to be part of a professional organization. Is it for a merit badge? Something to put on your resume? A means to access the legislators? A forum to interact with other emergency care professionals, not just physicians? A medium for accessing continuing medical education?

USAEM costs just $25/year.
Find out for yourself, just how much the others cost, and judge whether they are really worth it.

In the meantime, have a great weekend and a Happy 4th of July!

Friday, May 25, 2007

Reality is how I choose to see my world, not an image dictated by others.

There once was a time when I saw my life as never meeting expectations. I wasn't young enough, slim enough, tall enough or smart enough. I didn't have the right car, clothes, house, income, attitude or career. I wasn't raised in the right community, I didn't hang around with the right people, have the right ethnic heritage, nor go to the right school. I was foolish enough to believe this was reality.

'Reality' was, I was a failure, an odd ball, an outcast.

Then one day I felt this gentle nudging. I can't quite pinpoint the event or moment. Was it created in loss or was it realized in a moment of joy? But I began to see through the barriers of the world and there, just beyond them, I discovered "Hope."

Here is what is real in my world today.

The warmth of my wife lying next to me at night giving me a sense of security and reminding me of love.

The sound of my sons' voices confirming that all is well with them and knowing that they are my greatest contribution to the world.

My Border Collie, Dooby, wagging her tail when I come home...she's always happy to see me. Sometimes she's the only one!

The velvet touch of a rose petal between my fingers and the sweet smell it leaves behind reminds me that the finest things present to all my human senses.

The brightness of the sun rise cries out "Celebrate! You are born again into a new day.

As an emergency physician, the gentle touch of a stranger's hand when first we say hello and connect palm to palm. The daily opportunity of fixing someone's medical problem.

Considered a ritual, a formality by some, I find it a moment of connection on a spiritual level.

The sounds of life carried by the wind; the cries of a hawk, the waves crashing on the shore, the chatter of an anxious squirrel, and the bells on a distant ice cream truck carrying with it the sweet cream treats of childhood memories.

The tears I shed for someone's pain.

The smell of fresh cut grass.


The wisdom of someone older [or younger] than I.
The wisdom of an innocent child.

The taste of mashed sweet potatoes and maple syrup (a concoction my wife makes for our older son).

The smell of my wife's fantastic cooking, producing instant flashbacks of family gathered around in celebration of life.

The sound, "You have mail!" on my computer (actually that one's not always so great).

The words, "Thank you!" "My friend" "Love" and "Hope."

The knowledge that, regardless of what other people say, I am who I am and who I want to be. My community truly appreciates me for being an emergency medicine specialist, even if some organizations try to malign me, just because I don't have the same letters after my name as they do. If they experienced the real joy of their work, as I do, then I doubt they would target others in the way they [presently] do. However, I also have great HOPE that they will learn to love and embrace everyone who is providing care for others.

Watching TV commercials about fast cars, designer clothes, being thin, being young, being wealthy and knowing they aren't as important as being happy with who I reality!

[Mildly adapted and modified from Bob Perks, for the life of this ER doc]

Saturday, May 19, 2007

A Reminder About The Nature Of The Beast

Mission Statement:

Membership in AAEM is open to anyone who supports the following mission statement of the organization.

The American Academy of Emergency Medicine (AAEM) is the specialty society of emergency medicine. AAEM is a democratic organization committed to the following principles:

1. Every individual should have unencumbered access to quality emergency care provided by a specialist in emergency medicine.

2. The practice of emergency medicine is best conducted by a specialist in emergency medicine.

3. A specialist in emergency medicine is a physician who has achieved, through personal dedication and sacrifice, certification by either the American Board of Emergency Medicine (ABEM) or the American Osteopathic Board of Emergency Medicine (AOBEM).

Above is an excerpt from a webpage from the American Academy of Emergency Medicine (AAEM). In case you haven't heard much about them, they have been in business (yes, business, meaning profit-motivated) for over 14 years, and in that time they have managed to establish 4,000 members (one tenth of the emergency physician workforce in America), most of whom were 'press-ganged' with a strange offer of free membership when they were impressionable students in med-school.

AAEM has decided to take on the mantle of defining what exactly is an emergency medicine specialist, much like certain politicians would define a good American, up until recently, as someone who supported the war in Iraq.

The trouble with making such definitions is that you can't fool all of the people all of the time. However, as AAEM has clearly demonstrated, you can fool some of the people all of the time.

AAEM has focused primarily on aiming to artificially reduce the number of emergency medicine specialists (by redefining what that means, and asking legislators to carve the AAEM definitions in Law), for no other reason than to shorten the supply, and thus increase the pay for those lucky few who remain (who also happen to fit with AAEM's definition). I think it is a fair comment to say that such a policy is self-serving, and monopolistic.

AAEM has long argued (with their "it's not the test, it's the training" wailing) that only a physician who has completed an EM residency can be considered an EM specialist. This explained their support for FCEP's annual [failed] bill to outlaw the designation of EM specialist to all those who are not residency trained in EM.

Those who have grandfathered in ABEM would be wise to abandon their loyalty to AAEM, chiefly because you are nothing more than a source of revenue for them. AAEM has no interest in protecting grandfathered ABEM physicians. If they did, then why are you so limited in your employment opportunities? Why do all the ads in AAEM-backed publications advertise for residency-trained emergency physicians? This EXCLUDES the Grandfathered ABEM physicians.

Only ACEP, which has taken the position of protecting the Legacy Emergency Physicians, and USAEM, which welcomes all emergency physicians of whatever cloth, will protect you. AAEM has never taken the initiative to protect those emergency physicians who did not do an EM residency. This includes people like Professor Judith Tintinalli, and the past-president of ACEP, Dr. Rick Blum, amongst many other noted people in our specialty.

I know AAEM has long been considered full of "crazies", and this by rather eminent leaders in EM, but I think it's high time we put these so-called "crazies" back into the correct observational wing from whence they came. AAEM's recent president, played war games with American Emergency Medicine, and then went off home to Lebanon, to start a residency program! LAEM is now courting the Europeans with their Sorrento conference in Italy, while at the same time maligning other European trained emergency physicians (yes, me). Hypocrisy? Well I think it's time this was exposed.

In an act of desperation (momentary glimpse of reality?), AAEM recently offered to merge with ACEP recently, in what they called the 'unity proposal'. Wisely, ACEP rejected such a proposal. Now AAEM is suddenly announcing (EP Monthly, April, page 3) that it will overtake ACEP in membership numbers. Hot air? Bitterness? Does it matter? What matters is that we can ignore the 'crazies' and the 'fascists', imagining they are just a curiosity, but if we don't expose them for the frauds that they are, they may just 'get lucky' and get some unsuspecting legislature to pass one of its crazy bills! Even MedScape has been fooled into believing that AAEM is the foremost voice for emergency physicians! Who next?

What is important is the patient, and your ability to care for them. It is very important that you forward this email to all AAEM members who you think may have been duped into membership with an organization that doesn't really support them.

Fortunately, the Institute of Medicine declared that core competencies are more important for the designation of emergency medicine specialist, and not board certification. The IOM's statement was in direct opposition to the AAEM definition.

Who are you going to believe? The IOM or AAEM?

Why am I writing this letter? Because I have had direct communication with AAEM leaders and their words are very telling. When asked whether there was any place for prejudice or discrimination amongst professionals in emergency medicine, I was stunned that I didn't get a simply "No". Instead, I received a convoluted answer involving some incomprehensible condition that ABEM approved. So AAEM's morals are entirely dependent on what is convenient to them, it seems.

Leave AAEM. Advise your friends to leave AAEM. Join ACEP. Join USAEM. Do the right thing for America. Be part of the solution. Don't be part of the problem. We need to stop the problem.

Thanks for reading,

Just a regular 'emergency physician specialist'.

Tuesday, May 8, 2007

Tribal Thinking & The Ultimate Confounder

Today, I exchanged some interesting communication with the leader of an organization that has been affectionately dubbed "EM's crazy uncle". I asked him to state very simply, "yes or no", that there was no place in the House of Emergency Medicine, for prejudice and discrimination.

Unfortunately, I did not receive a simple yes or no, as one might expect from most well-meaning and well-intentioned folk of good conscience. Nope. Instead I got an answer that was extremely conditional upon another condition that was itself conditional upon something to do with whether ABEM agreed that prejudice and discrimination were ok - or something like that......I think.

His answer was a touch confusing. Honestly, I did ask him to use small words, because my intellect was not as vast as his, but alas, I was still unsure what he was going on about.

Let me share with you some words from a quantum physicist, Fred Alan Wolf. I think they speak very well to the current debate on who should practice emergency medicine:

If I am a member of a tribe, my concept of self is different than if I am, say, a member of a closed family unit. My behavior, in turn, depends on how I see myself. For example, soldiers fighting in a war view themselves as part of a larger unit; and they behave quite differently toward those outside of their unit, particularly enemies, than they would if they were village people greeting strangers.

Thus, how we become aware of the world around us is to a large extent dependent on how we think about our individuality in relation to our environment.

Think about what group or "tribe" you most identify with and how this identification determines your thoughts, beliefs and behavior. What happens when you change your tribal affinity? A new "you" emerges.

Dr Wolf's words are rather enlightening, to say the least. They teach me not to be so passionately against any group or organization. I shouldn't even mock them, like calling them "crazy uncle" etc. In fact, I should warmly embrace them.

Jesus said we should love our enemies. I agree.

This month's Annals of Emergency Medicine, contains a very comprehensive and balanced article (pp. 614-617) by Maryn McKenna, on the state of play in EM today, and about how the IOM has somehow rekindled the debate on who should practice EM. It's an awesome read, and discussed every group's position. I'll leave it to you to decide who might be short of a full deck, and who might be in such a political quagmire, that 'doing the right thing' would require far too much red tape.

The article also touches on the key to the whole problem: money. Ms. McKenna calls it 'the ultimate confounder'.

Certain groups hide behind unproven arguments that quality will fall if we allow "just anybody" to practice EM, when the real truth of the matter is that they might not be able to upgrade from a $500K house to a $1.3m house. They might not be able to buy a vacation condo in Miami or Vegas. They might not be able to take another vacation to the Mediterranean - perhaps on the west coast of Italy in the shadow of Vesuvius!

Who will pay the price for these attempts at artificially reducing the number of emergency physicians in the USA? The patients. Such disgracefully bigoted policies will limit access to emergency care for so many people. There are already over 60 million people in America with no health insurance. Some kids can't even get a bloody vaccine!

And yet, some groups feel so strongly that ERs should only be manned by those physicians who have completed an EM Residency. What utter nonsense.

Even the pro-EM-residency organization, Society for Academic Emergency Medicine, declared in a 2004 study that "residency training will not supply enough specialists to meet the demand for emergency physicians for 30 years". I guess the left hand doesn't really know what the right hand is doing.

I work for the United States Alliance of Emergency Medicine. We comprise, emergency physicians (of all cloths, colors, nationalities, training and board certification), emergency nurses and paramedics. We embrace and welcome everybody. There should not be any tribal insurgencies. The whole world has witnessed what that kind of thinking results in.

I invite all members of other organizations that are clearly prejudicial and discriminatory, to join USAEM, and connect with like-minded, good people, of good conscience. People who can give you a straight answer, and are intellectually honest. People who do not think with their bank accounts.

I dream that one day, the various tribes will put their differences aside, and come together under one big tent - as big as we want it to be. It's not the 17th century any more. There is no room for restraints of trade or the creation of monopolies. Let's all be friends.

In the words of Rodney King, "why can't we all just get along?"
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Monday, April 23, 2007

Nice But Slow

We've all seen them. We all know who they are.

They all know who they are!

You see his name next to yours on the schedule, working alongside you, and you groan. Actually, sometimes you scream. Maybe you'll even try to switch your shift, using the excuse that you have to take your kids somewhere. Maybe you'll just happen to fall ill that day.

Yes, I'm talking about that wonderful emergency physician, the one who's been doing it for years. The one who sees patients at the whopping average rate of 1 per 90 minutes. Yet, he seems oblivious to the frustration he's causing. He smiles, apparently without reason, and is just so amazingly harmonious and agreeable to everyone. The secretaries like him. The nurses like him. Even his patients like him. Wouldn't you like your ER doc if he was able to pull a chair up and take the most detailed history you have ever had any physician take from you?

Those same ER docs are the ones who are fully aware that "they're going to have to kick me outta here, kicking and screaming, coz I aint leaving on my own." Yes you know who they are.

These doctors are the ones who inspire discussion about RVUs, and about productivity bonuses. These guys are often described as "well he's such a nice guy, but he's just so God awful slow". Whenever you work alongside him, the nurses repeatedly come up to you to see their critical patients, yet unassigned to a physician, even though you have 10 patients and he has 3.

Hell, the nurses will even come up to you for help with his patients!

So you either suck it up, or you do something about it. But what can you do? Can you complain to anyone? What can the medical director do? What can the nurses do? For that matter, what can the 'Nice But Slow' (NBS) doc do?

Occasionally, a petition from the nurses to the CEO may lead to a dismissal in such a scenario. But how likely is that, given he's just SO DAMNED NICE and actually quite a pleasant person to chat to. How can you possibly conspire to have someone fired who actually greets you with such a nice smile whenever you start your shift?

The medical director, I suppose, could tell the NBS doc to "speed up, or else". Or else what?

He's usually in his fifties, but he might even be in his thirties. There's no typical profile, except that he's always nice. The strange thing is, it's the fast docs who are not always so harmonious and pleasant. Maybe because they're so busy. Maybe because they get paid the same as the NBS doc but do 4 times as much work. Maybe because they consequently expose themselves to 4 times the medicolegal liability, and it's just getting old. Also, even though he's fast, there might be several nurses and other coworkers who would love to see him go. He makes them "work too hard" because he's constantly asking them to call physicians, put orders into the computer and get EKGs, orthostatics and blood sugars, at every opportunity. The coworkers just think he's a freaky stressed out guy, simply because he's carrying the workload. How interesting.

Mind you, there are some fast docs who are actually quite pleasant and all smiles. They have discovered the 'best of both worlds'. Be liked by your co-physicians as well as your other coworkers, as well as your patients. Is it such a tightrope? Is it such a big juggling act? Well, of course it is, but I do believe it's possible.

Providing quality, with quantity, as well as having a great spirit about, that is, being harmonious and agreeable and acting like you're enjoying your work, is actually possible.

So, getting back to Dr. NBS. What can we do about him? Short answer: nothing. Absolutely nothing. Let nature decide what happens to him. You just firmly plod along, doing your own thing, at YOUR own pace, no matter how fast or slow that may be, and do the very best for your patients. Don't be tempted to join in when people make comments about how slow Dr. NBS is being. Just let it slide and do your own work, and do it well.

That's all that matters.

So take it easy. Go to work. Smile. Enjoy yourself. Work like a Ferrari - fast and stunning, and nice to hang out with. Don't work like an old vintage classic, also nice to hang out with, but pretty darned slow. That's quaint, but practically useless in a modern emergency department.

As my Mom always says "You be good", and don't worry about the other guys.

Wednesday, April 11, 2007

Another day - another blog...

I was reading ACEP News (the March 10th issue, which reached my remote home in St. Louis, yesterday on April 10th) about the proposed merger between AAEM and ACEP.

This is rather an exciting development. Does it mean that AAEM, who proposed the merger, will finally abandon their ideology that only those ER docs who did ER residencies should be working in the ERs? Perhaps they have finally realized that such an ideology cannot possibly be consistent with:
  1. staffing all the emergency departments in the USA
  2. providing adequate emergency medical care to all our patients
  3. practising good medicine, because a certain training (any) does not equal core competency
  4. long-overdue unification of all ER docs
Or perhaps they haven't realized this, but they will. AAEM must understand that ACEP has an obligation to a certain important part of its membership, the Legacy Emergency Physicians, who actually founded the College in the first place. AAEM must know that a merger means they will have to abandon their prejudices, much like Iran must abandon its prejudices against Israel, if they are to be recognized by the world's peaceloving nations. Much like Lebanon's Hezbullah and Palestine's Hamas had to abandon their hatred against Israel, to be accepted at the conference table. I think the past president of AAEM, Dr. A. Kazzi, just returned home to Lebanon didn't he?

Anyway, the important thing is unity. All Emergency Physicians must be treated equally if they are 'core competent'. They do not have to be board certified, but if they are, they should be praised. There should be no antagonism against ABEM or BCEM, just because people belong to one group or another. There should be universal embracing of all cloths, and all types of training, whether it is in a supervised arena or an unspervised 'in-the-field' arena.

The important thing is core competencies. AAEM may finally be realizing this and that they are doomed if they do not merge with common sense - that is - merge with the majority - that is, ACEP.

Well done AAEM, for being able to see beyond your outdated ideologies.