Your Online Image: Policy From the ACP

by Sandra Adamson Fryhofer, MD from Medscape

Introduction

A new policy statement from the American College of Physicians (ACP) and the Federation of State Medical Boards (FSMB)^[1] takes a closer look at online patient/physician relationships in social media and other “Web 2.0″ interactions. The policy does not address or examine telemedicine, e-prescribing or e-diagnosing, or electronic health record issues.

The study is published in Annals of Internal Medicine, but how appropriate that the paper made its debut at a site close to Silicon Valley.^[1]

“You” Online

An online presence is becoming essential for health professionals. When is the last time you used a phone book to find a phone number or location? With smartphones getting smarter and tablets getting faster (and smaller), we all want access to information at our fingertips and on demand.

Just about everyone uses the Internet as their information source. Patients use it as a source of medical information. Physicians use it to stay current with the latest medical advances. In fact, a Pew Internet survey ranked seeking health information as the third most popular online activity.^[2]

Staying connected is now an engrained part of our culture. Networking sites, media-sharing sites, and blog platforms have increased in popularity. But the introduction of social media is also changing the rules. The physician/patient interface is now a little more complicated. This policy paper sets some guidelines to make sure you don’t cross the line.

Connectivity — Without Crossing the Line

The policy paper includes a quick-look table matching available online activities with potential pitfalls and providing recommended safeguards. It’s a must-read. Protecting patient confidentiality and preserving trust are essentials for a positive patient/physician relationship.

Pitfalls of Texting

The policy paper also discusses the pitfalls of texting with immediate expectations. Text messages are short and quick. Some pharmacies and insurers are piloting their use for pharmacy refills and appointments. Security and confidentiality are valid concerns. These technologies also present unintended expectations of immediate access (and answers). The truncated format limits detailed explanation and could increase odds that the message could be misconstrued. These reasons are why the policy paper cautions against routine texting for medical interactions — even for established patients.

Who Is Googling You?

Everybody’s doing it! Patients do it. Peers do it. Potential employers also do it (and so do medical school admission offices and residency training programs.) Your online image influences public, patient, and peer perceptions.

Do a self online audit. Find out what others are reading about you. The policy paper recommends doing this routinely and correcting inaccurate information. Unfortunately, they give no specifics as to how to accomplish the goal of rectifying mistakes and inaccuracies in what others have posted.

The paper does suggest a possible remedy for mitigating misrepresentations on physician ranking Websites. Although there is no way to have these deleted, the paper proposes establishing a professional profile “so that it ‘appears’ first during a search” as a means of controlling what patients read.

Pause Before Posting

Carefully consider the content of what you post. Because postings on the Internet are archived, they are essentially permanent. That’s why reflecting before reacting is a good idea.

Online perceptions include not only what is written about you, but also photos. Provocative or inappropriate postings indicate poor judgment and adverse consequences, including medical board complaints.

ACP and FSMB also advise against “airing frustrations” and “venting” in online forums. Such postings can be misconstrued and can come back to haunt you!

Know the Rules, and Follow Them

When transferring patient information electronically, be sure to stay compliant with the Health Insurance Portability and Accountability Act (HIPAA). Patients should also be made aware of the inherent security risks in communicating via email.

Some states’ laws (for example those in Hawaii) do not require a preexisting relationship for emailing between patients and physicians, a practice that is not supported by ACP or the FSMB. The policy paper also points out that some state medical boards consider emailing a violation if the physician is not licensed in the state in which the electronic communication is received. No source or specific examples were given, however.

To Friend or Not to Friend? Setting Personal/Professional Boundaries

The policy gives guidance for responding to online “friend” requests from patients: Don’t do it. The position paper specifically discourages “friending” patients on personal social media sites, such as Facebook. This blurs patient/physician boundaries.

Having a separate personal and professional online presence can help mitigate this problem. It is acceptable to use professional profiles in networking and community outreach.

Patient-targeted Googling also raises red flags: “curiosity, voyeurism, and habit.” This type of digital tracking could undermine trust in the patient/physician relationship.

Final Words: Online Professionalism Is Paramount

Physicians are professionals. One of the premises of being a professional is that the public expects us to self-regulate. This policy paper provides a good starting point for online relationship discussions. These premises also apply to physicians in training. The authors acknowledge that this policy is a starting point in dialogue and will require more fine-tuning as physicians and patients navigate the online terrain.

Can “workplace stress” be defined?

We hear a lot about stress, but what is it? Taber’s Cyclopedic Medical Dictionary defines stress as “the result produced when a structure, system or organism is acted upon by forces that disrupt equilibrium or produce strain”. In simpler terms, stress is the result of any emotional, physical, social, economic, or other factors that require a response or change. It is generally believed that some stress is okay (sometimes referred to as “challenge”or “positive stress”) but when stress occurs in amounts that you cannot handle, both mental and physical changes may occur.

“Workplace stress” then is the harmful physical and emotional responses that can happen when there is a conflict between job demands on the employee and the amount of control an employee has over meeting these demands. In general, the combination of high demands in a job and a low amount of control over the situation can lead to stress.

Stress in the workplace can have many origins or come from one single event. It can impact on both employees and employers alike. As stated by the Canadian Mental Health Association:

Fear of job redundancy, layoffs due to an uncertain economy, increased demands for overtime due to staff cutbacks act as negative stressors. Employees who start to feel the “pressure to perform” can get caught in a downward spiral of increasing effort to meet rising expectations with no increase in job satisfaction. The relentless requirement to work at optimum performance takes its toll in job dissatisfaction, employee turnover, reduced efficiency, illness and even death. Absenteeism, illness, alcoholism, “petty internal politics”, bad or snap decisions, indifference and apathy, lack of motivation or creativity are all by-products of an over stressed workplace.

From: Canadian Mental Health Association, “Sources of Workplace Stress” Richmond, British Columbia.

I have heard stress can be both good and bad. Is this true?

Some stress is normal. In fact, it is often what provides us with the energy and motivation to meet our daily challenges both at home and at the workplace. Stress in these situations is the kind that helps you “rise” to a challenge and meet your goals such as deadlines, sales or production targets, or finding new clients. Some people would not consider this challenge a type of stress because, having met the challenge, we are satisfied and happy. However, as with most things, too much stress can have negative impacts. When the feeling of satisfaction turns into exhaustion, frustration or dissatisfaction, or when the challenges at work become too demanding, we begin to see negative signs of stress.

What are examples of things that cause stress at the workplace?

In the workplace, stress can be the result of any number of situations. Some examples include:

Adapted from: Murphy, L. R., Occupational Stress Management: Current Status and Future Direction. in Trends in Organizational Behavior, 1995, Vol. 2, p. 1-14, and UK Health & Safety Executive (HSE) “Managing the causes of work-related stress: A step-by-step approach using the Management Standards”, 2007.

Can stress cause health effects?

Yes, stress can have an impact on your overall health. Our bodies are designed, pre-programmed if you wish, with a set of automatic responses to deal with stress. This system is very effective for the short term “fight or flight” responses we need when faced with an immediate danger. The problem is that our bodies deal with all types of stress in the same way. Experiencing stress for long periods of time (such as lower level but constant stressors at work) will activate this system, but it doesn’t get the chance to “turn off”. The body’s “pre-programmed” response to stress has been called the “Generalized Stress Response” and includes:

• increased blood pressure
• increased metabolism (e.g., faster heartbeat, faster respiration)
• decrease in protein synthesis, intestinal movement (digestion), immune and allergic response systems
• increased cholesterol and fatty acids in blood for energy production systems
• localized inflammation (redness, swelling, heat and pain)
• faster blood clotting
• increased production of blood sugar for energy
• increased stomach acids

From: Basic Certification Training Program: Participant’s Manual, Copyright© 2006 by the Workplace Safety and Insurance Board of Ontario.

Stress can contribute to accidents/injuries by causing people to:

• sleep badly
• over-medicate themselves and/or drink excessively
• feel depressed
• feel anxious, jittery and nervous
• feel angry and reckless (often due to a sense of unfairness or injustice)

When people engage in these behaviours or are in these emotional states, they are more likely to:

• become momentarily (but dangerously) distracted
• make errors in judgment
• put their bodies under physical stress, increasing the potential for strains and sprains
• fail in normal activities that require hand-eye or foot-eye coordination.

Stress can also lead to accidents or injuries directly by not giving the person the control necessary to stop the threat to their physical well-being.

Luckily, there are usually a number of warning signs that help indicate when you are having trouble coping with stress before any severe signs become apparent. These signs are listed below.

How do I know if someone is (or if I am) having trouble coping with stress?

There are many different signs and symptoms that can indicate when someone is having difficulty coping with the amount of stress they are experiencing:

Physical: headaches, grinding teeth, clenched jaws, chest pain, shortness of breath, pounding heart, high blood pressure, muscle aches, indigestion, constipation or diarrhea, increased perspiration, fatigue, insomnia, frequent illness.

Psychosocial: anxiety, irritability, sadness, defensiveness, anger, mood swings, hypersensitivity, apathy, depression, slowed thinking or racing thoughts; feelings of helplessness, hopelessness, or of being trapped, lower motivation.

Cognitive: decreased attention, narrowing of perception, forgetfulness, less effective thinking, less problem solving, reduced ability to learn; easily distracted.

Behavioural: overeating or loss of appetite, impatience, quickness to argue, procrastination, increased use of alcohol or drugs, increased smoking, withdrawal or isolation from others, neglect of responsibility, poor job performance, poor personal hygiene, change in religious practices, change in close family relationships.

Below is a quiz from the Canadian Mental Health Association of Ontario you can take to help identify your stress levels:

Adapted from: What’s Your Stress Index?  Canadian Mental Health Association, Ontario (no date).

Interpretation of your score (based on the number of “Yes” selections):

0-5:  There are few hassles in your life.  Make sure though, that you are not trying to deliberately avoid problems.

6-10: You’ve got your life in fairly good control.  Work on the choices and habits that could still be causing you some unnecessary stress in your life.

11-15: You are approaching the danger zone.  You may be suffering stress-related symptoms and your relationships could be strained.  Think carefully about choices you’ve made and take relaxation breaks every day.

16-25: Emergency!  It is critical that you stop and re-think how you are living; change your attitudes and pay careful attention to diet, exercise and relaxation.

Do all of these signs or symptoms happen all at once and what level of help should be sought?

No, not normally. The signs and symptoms from stress tend to progress through several phases or stages. The phases can be described as below:

From: Anschuetz, B.L. “The High Cost of Caring: Coping with Workplace Stress” in Sharing: Epilepsy Ontario. Posted 29 November 1999.

What are some general tips for dealing with stress at the workplace?

Since the causes of workplace stress vary greatly, so do the strategies to reduce or prevent it.

Where stress in the workplace is caused, for example, by a physical agent, it is best to control it at its source. If the workplace is too loud, control measures to deal with the noise should be implemented where ever possible. If you are experiencing pain from repetitive strain, workstations can be re-designed to reduce repetitive and strenuous movements. More detailed information and suggestions are located in the many other documents in OSH Answers (such as noise, ergonomics, or violence in the workplace, etc.) or by asking the Inquiries Service.

Job design is also an important factor. Good job design accommodates an employee’s mental and physical abilities. In general, the following job design guidelines will help minimize or control workplace stress:

• the job should be reasonably demanding (but not based on “sheer endurance”) and provide the employee with at least a minimum of variety in job tasks
• the employee should be able to learn on the job and be allowed to continue to learn as their career progresses
• the job should comprise some area of decision-making that the individual can call his or her own.
• there should be some degree of social support and recognition in the workplace
• the employee should feel that the job leads to some sort of desirable future

What can the employer do to help?

Employers should assess the workplace for the risk of stress. Look for pressures at work which could cause high and long lasting levels of stress, and who may be harmed by these pressures. Determine what can be done to prevent the pressures from becoming negative stressors.

Employers can address stress in many ways.

DO

• Treat all employees in a fair and respectful manner.
• Take stress seriously and be understanding to staff under too much pressure.
• Be aware of the signs and symptoms that a person may be having trouble coping with stress.
• Involve employees in decision-making and allow for their input directly or through committees, etc.
• Encourage managers to have an understanding attitude and to be proactive by looking for signs of stress among their staff.
• Provide workplace health and wellness programs that target the true source of the stress. The source of stress at work can be from any number of causes – safety, ergonomics, job demands, etc. Survey the employees and ask them for help identifying the actual cause.
• Incorporate stress prevention or positive mental health promotion in policies or your corporate mission statement.
• Make sure staff have the training, skills and resources they need.
• Design jobs to allow for a balanced workload. Allow employees to have control over the tasks they do as much as possible.
• Value and recognize individuals’ results and skills.
• Provide support. Be clear about job expectations.
• Keep job demands reasonable by providing manageable deadlines, hours of work, and clear duties as well as work that is interesting and varied.
• Provide access to Employee Assistance Programs (EAPs) for those who wish to attend.

DO NOT

• Do not tolerate bullying or harassment in any form.
• Do not ignore signs that employees are under pressure or feeling stressed.
• Do not forget that elements of the workplace itself can be a cause of stress. Stress management training and counselling services can be helpful to individuals, but do not forget to look for the root cause of the stress and to address them as quickly as possible.

Is there anything I can do to help myself deal with the stress I am experiencing at work?

In many cases, the origin of the stress is something that cannot be changed immediately. Therefore, finding ways to help maintain good mental health is essential. There are many ways to be proactive in dealing with stress. In the workplace, you might try some of the following as suggested by the Canadian Mental Health Association:

Learn to relax, take several deep breaths throughout the day, or have regular stretch breaks. Stretching is simple enough to do anywhere and only takes a few seconds.

Take charge of your situation by taking 10 minutes at the beginning of each day to priorize and organize your day. Be honest with your colleagues, but be constructive and make practical suggestions. Be realistic about what you can change.

From: Canadian Mental Health Association, “Sources of Workplace Stress” Richmond, British Columbia.

Are there organizations that can help?*

Yes, there are many. Your family doctor can often recommend a professional for you. Other examples include the Employee Assistance Programs (EAP) or associations such as the Canadian Mental Health Association (CMHA) or the Canadian Centre on Substance Abuse (CCSA) to name just a few.

• EAP programs are confidential, short term, counselling services for employees with problems that affect their work performance. The services of EAP providers are often purchased by your company. Check with your human resources department (or equivalent) for contact information.
• CMHA ’s programs are meant to ensure that people whose mental health is endangered will find the help needed to cope with crisis, regain confidence, and return to community, family and job.
• The CCSA  promotes informed debate on substance abuse issues, and disseminates information on the nature, and assists organizations involved in substance abuse treatment, prevention and educational programming.

(*We have mentioned these organizations as a means of providing a potentially useful referral. You should contact the organization(s) directly for more information about their services. Please note that mention of these organizations does not represent a recommendation or endorsement by CCOHS of these organizations over others of which you may be aware.)

For more information on mental health, see the OSH Answers:

• Mental Health – Introduction
• Mental Health – Psychosocial Risk Factors in the Workplace
• Mental Health at Work

What else can I do to improve my overall mental health?

Good mental health helps us to achieve balance and cope with stressful times.

From: Canadian Mental Health Association  - National Office

Other mental fitness tips include:

• Give yourself permission to take a break from your worries and concerns. Recognize that dedicating even a short time every day to your mental fitness will reap significant benefits in terms of feeling rejuvenated and more confident.
• “Collect” positive emotional moments – Make a point of recalling times when you have experienced pleasure, comfort, tenderness, confidence or other positive things.
• Do one thing at a time – Be “present” in the moment, whether out for a walk or spending time with friends, turn off your cell phone and your mental “to do” list.
• Enjoy hobbies – Hobbies can bring balance to your life by allowing you to do something you enjoy because you want to do it.
• Set personal goals – Goals don’t have to be ambitious. They could be as simple as finishing a book, walking around the block every day, learning to play bridge, or callingyour friends instead of waiting by the phone. Whatever goal you set, reaching it will build confidence and a sense of satisfaction.
• Express yourself – Whether in a journal or talking to a wall, expressing yourself after a stressful day can help you gain perspective, release tension, and boost your body’s resistance to illness.
• Laugh – Laughter often really is the best medicine. Even better is sharing something that makes you smile or laugh with someone you know.
• Treat yourself well – Take some “you” time – whether it’s cooking a good meal, having a bubble bath or seeing a movie, do something that brings you joy.

Adapted from: Canadian Mental Health Association Mental Fitness Tips .

from Canadian Centre for Occupational Health and Safety

Additional Links:
Stress and Balance Within

Ginde, Adit A. MD, MPH; Camargo, Carlos A. Jr. MD, DrPH

There will not be enough emergency medicine residency trained physicians to cover our nation’s emergency departments for many years. (Acad Emerg Med 2008;15[12]:1317.) This shortage is even more pronounced in smaller and rural EDs and in the face of continually increasing demand for emergency care.

So who covers these EDs? In 2008, 31 percent of physicians practicing in EDs — more than 12,000 physicians — were not emergency medicine residency trained or emergency medicine board certified. (Ann Emerg Med 2009;54[3]:349.) They are family physicians, internists, surgeons, and pediatricians who provide emergency care when an emergency medicine-trained physician is not available. This emergency medicine workforce shortage was a major topic of the 2009 Future of Emergency Medicine Summit, which brought together representatives of the leading emergency medicine organizations. (Schneider SM, et al. The future of emergency medicine. Ann Emerg Med 2010; in press.) Numerous potential solutions were discussed, including increasing emergency medicine residency slots, loan repayment for emergency physicians, joint emergency medicine-family medicine training, and using scribes to improve efficiency. One recommendation that has become increasing popular is the use of midlevel providers such as physician assistants and nurse practitioners.

Indeed, the introduction of midlevel providers to emergency care is already occurring in great numbers. In 2005, 13 percent of all U.S. ED visits were covered by a midlevel provider, up from only four percent in 1993. (Am J Emerg Med 2010;28[1]:90.) At first glance, this may seem like a win-win scenario. Midlevel providers help expand the efficiency of emergency physicians, and cover some of the workforce gap. Their cost to the hospital is lower than a physician’s, and at least for minor presentations, patient satisfaction appears to be high. (Am J Emerg Med 2000;18[6]:661.) An increasing scope of practice and level of autonomy, however, calls into question whether midlevel providers are collaborating with emergency physicians or actually replacingthem.

We fully support emergency medicine residency training, and believe that emergency medicine board certified physicians are the gold standard for providers in the ED. When emergency medicine-trained physicians are unavailable or unwilling to cover some EDs, such as smaller and rural EDs, however, many non-emergency medicine-trained providers, both physicians and midlevel providers, continue to fill the void. While physicians attract a greater amount of criticism and scrutiny, midlevel providers, who do not have formal emergency medicine training and fewer overall years of medical training than physicians, are often embraced as a solution to the workforce shortage.

While NPs are licensed to practice independently in some states, PAs must collaborate with physicians. The scope of practice and degree of autonomy for both groups is state-dependent. Neither group has developed accredited emergency medicine training programs for specialization in emergency care. Yet independent practice is becoming increasingly common. (See figure.) In paging through ED job announcements, we have encountered postings that state, “We are currently seeking a PA who is comfortable working autonomously in our ED.” In 2005, five percent of all ED visits nationwide were seen by midlevel providers without onsite physician involvement, up from one percent in 1993. (Am J Emerg Med 2010;28[1]:90.)

But indirect physician supervision of PAs and their independent practice is legal, isn’t it? Supervision and scope of practice for midlevel providers are defined at the state level. Most states allow provision of emergency care and define supervision as the availability of a physician, but participation in care or even physical presence in the facility is often not required. Physician supervision by co-signing charts or prescriptions days to weeks after the ED visit is occurring throughout the country, although it is unknown how widespread this practice is. How much oversight is truly being provided for these patients?

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But isn’t this is only an issue for rural EDs, where any provider is better than no provider? Not really. National data show that 86 percent of midlevel provider visits without physician involvement are in urban EDs. (Am J Emerg Med 2010;28[1]:90.) While the number of these visits has remained stable in rural EDs, they have markedly increased in urban EDs over the past decade. Emergency physician workforce shortages are probably not driving this as much as practical and financial considerations; ED administrators may hire less expensive midlevel providers instead of emergency physicians. With emergency medicine residency graduates having difficulty obtaining jobs in some desirable urban markets, it’s possible midlevel providers may actually be taking jobs away from emergency medicine residents rather than solving the emergency medicine workforce shortage and maldistribution.

What about acuity? Midlevel providers don’t really need a physician to directly supervise the care of patients with obvious ankle sprains and minor lacerations. This may be true, and data support the quality of care by independent midlevel provider care for minor ED presentations. (Lancet 1999;354 [9187]:1321.) Of ED patients seen in 2005 by midlevel providers without direct physician supervision, however, six percent arrived by ambulance, 37 percent had urgent/emergent acuity, and three percent were admitted to the hospital. (Am J Emerg Med2010;28[1]:90.) While these acuity data are lower than those for physicians in the ED, the role of midlevel providers, who may practice without on-site physician involvement, has clearly extended beyond minor presentations.

Limited data address the quality and patient safety of midlevel provider care of higher acuity ED patients. A recent study of 4,029 visits for acute asthma in 63 U.S. EDs found that unsupervised midlevel providers had a significantly lower quality of ED asthma care, compared with physician-supervised midlevel providers and with physicians alone. (Am J Emerg Med 2010;28[4]:485.)

The latter groups, in which physicians were directly involved, provided care of similar quality. While this is a single study of one condition, acute asthma care has well-defined treatment pathways and evidence-based national guidelines that should create more uniform care than other acute conditions. These data support a view that midlevel providers should collaborate with, rather than replace, emergency physicians, especially for higher acuity patients.

Midlevel providers have a major role in U.S. emergency care, and we support efforts to develop emergency medicine training, accreditation, and continuing medical education for PAs and NPs. Indeed, there are now several post-graduate emergency medicine training programs for PAs and NPs. Before moving forward with a midlevel provider-based “solution” to the emergency physician workforce shortage, we encourage more thoughtful discussion about training, scope of practice, and supervision. The growing acceptance of non-emergency medicine-trained midlevel providers practicing independently in EDs is difficult to reconcile with the often heated and absolute opposition to non-emergency medicine residency trained physicians. The ultimate goal of most emergency physicians and midlevel providers, regardless of their emergency medicine training and accreditation, is to provide effective and safe care for our patients. This should stay at the forefront of the emergency medicine workforce debate.

© 2010 Lippincott Williams & Wilkins, Inc.

A National Study Examining Emergency Medicine Specialty Training and Quality Measures in the Emergency Department.

Mathews SC, Kelen GD, Pronovost PJ, Pham JC.

Johns Hopkins University School of Medicine, Baltimore, MD.

PMID: 20716690 [PubMed - as supplied by publisher]

Full Text: EM Specialty Training and Quality Measures study

From the introduction of this paper:

“When patients present to the emergency department (ED) for care, they assume that they will be cared for by a physician qualified to diagnose and treat their ills. This trust is even more sacred in emergency settings because patients with emergent conditions generally do not have the opportunity to choose the location or provider who will render this care. For this reason, the American College of Emergency Physicians and the American Board of Emergency Medicine advocate specific training (ie, emergency medicine [EM] residency) for physicians who treat patients in EDs.

 Yet across the United States, only 69% of physicians who work in the ED are EM residency trained or EM board certified. Fewer than 40% of EDs have a majority of physicians with EM residency training, and only 1 state (Hawaii)adequate supply of EM-board-certified emergency physicians.

Although recent EM physicians are much more likely to be EM residency trained, this deficiency has been attributed  to at least 4 different causes: (1) overall shortage of EM-trained physicians; (2) because EM is a relatively young specialty, a significant proportion of the workforce is composed of so-called legacy emergency physicians (ie, those engaged in EM practice prior to the proliferation of EM specialty training programs); (3) the lower staff cost of hiring non-EM-trained physicians; and (4) the difficulty of recruiting specialty trained physicians to rural locations. This variability in training of ED physicians has elicited some controversy, but the impact of the differences in training on clinical outcomes has not been assessed. EM-trained physicians are less likely to have expensive malpractice claims against them compared with their non-EM-trained counterparts.

Whether specialty training when compared to care provided by generalists  leads to improved clinical outcomes for specific conditions has been reviewed more broadly in medicine, but not in the context of EM.

Because the Institute of Medicine’s 1999 report identified shortcomings in the quality of care in the US health system, there has been renewed emphasis on emphasis on identifying measures of quality and performance.

Treatment of acute myocardial infarction (AMI), pneumonia (PNA), and long bone fractures (LBFs) has been used to evaluate quality across EDs. These characteristics have been recognized as ED quality measures to varying extents. These measures evaluate the extent to which patients receive recommended therapies.”

Commentary:

Core Measures are a set of care processes developed by The Joint Commission, the nation’s predominant standards-setting and accrediting body in health care, to improve the quality of health care by implementing a national, standardized performance measurement system. The Core Measures were derived largely from a set of quality indicators defined by the Centers for Medicare and Medicaid Services (CMS). They have been shown to reduce the risk of complications, prevent recurrences and otherwise treat the majority of patients who come to a hospital for treatment of a condition or illness. Core Measures help hospitals improve the quality of patient care by focusing on the actual results of care.

This study was a national cross-sectional study of ED visits for 2003 through 2004 using the National Hospital Ambulatory Medical Care Survey (NHAMCS). The NHAMCS is administered by the Centers for Disease Control and Prevention’s NCHS and is endorsed by the Emergency Nurses Association, the Society for Academic Emergency Medicine, the American College of Emergency Physicians, and the American College of Osteopathic Emergency Physicians.  It is a national probability sample of visits to the EDs of non-governmental general and short-stay acute care hospitals located in the 50 states and the District of Columbia.

 As stated above, this study was performed using cross-sectional data culled from a national database of all 50 states, and is clearly of greater quality and inspires more confidence compared to the small studies often cited to support claims of the alleged superior skills of EM residency trained physicians over their experienced, non-EM residency trained ER colleagues ( AAEM: Board Certification, Articles on Quality of Care ). Aside from having small samples, these other studies  were performed with less stringent methodologies (mostly retrospective reviews)  performed in only one hospital or at most, compare one hospital with another, mostly examining the effects of the introduction of an ER residency training program, the results of which can not, by any stretch of the imagination, be extrapolated to demonstrate what the AAEM and ABEM claim, that EM residency trained physicians have significantly superior clinical outcomes compared with non-EM residency trained physicians.

This quality study shows otherwise. In the discussion, it is interesting to note that the authors are hesitant to state outright what their results show, namely that when looking at nationally defined clinical criteria, non-EM residency trained and EM residency trained physicians  give the same quality care.  Instead, they state that the measures they used

“may be too simple to demonstrate the value of EM physicians. Future efforts to assess the role of EM training in ED quality should focus more on measures that demonstrate the unique skills of EM-trained physicians.”

What “unique skills”? The authors themselves admit that they chose these measures based on quality studies endorsed by professional societies.  What the authors may be hesitant to acknowledge due to the controversy currently raging in the EM community, is that there is no significant difference in quality between EM residency trained physicians and experienced non-EM residency trained physicians, certainly not enough to warrant paying non-EM residency trained physicians much less and removing their much needed presence in the ERs.

I have been a practiced-trained emergency physician for more than 20 years, having just missed the ABEM window to sit for the boards. I sat for the American Board of Physician Specialties exams in emergency medicine in 1995, and have since re-certified. I am the medical director for a rural ED in North Carolina.

I am continually amazed at the emotion evoked by this subject, especially by residency trained emergency physicians. Are physicians like me taking jobs from the residency trained doctors? I can’t get one of you to even look at my ED; you prefer referral centers and a significantly higher number of patients. There is a crisis out here, and you guys are concerned about advertising? Where are these advertisements? As fellow physicians interested in patient care, wouldn’t you prefer that the rural emergency physicians calling you at least proved their competence in emergency medicine in some credible way? Go ahead, and blow your horn about your residency training; you deserve it. It is a great sacrifice you endured, and it made most of you better emergency physicians, much more so than the testing you do at a computer after a weeklong class.

But take a look outside your bubble of medical center meccas at the shambles that is rural health care secondary to a massive physician shortage. Our ED volume is growing exponentially as primary care disintegrates, and the economics require more physician extenders with less supervision. Wouldn’t it be nice if ACEP, ABEM, AOBEM, and AAPS could come together to show this country that we recognize the problem, that together we are going to ensure that they receive the best possible care no matter what ED they walk into, and that the physician they shake hands with is supported by his peers in the profession?

Meanwhile, I will continue working in the environment I have grown accustomed to and now prefer with the knowledge that there will always be work for me until the day I retire because no one is beating down our doors for a job. Someday soon, no one will want my job unless we work together.

Scott L. Korn, DO
Rutherfordton, NC

By TODD ACKERMAN
HOUSTON CHRONICLE

Oct. 29, 2010, 10:52PM

I don’t think the American College of Emergency Physicians and all the powers-that-be have the patients’ best interests at heart. These people are self-serving and self-absorbed. Their interest is to keep salaries very high for residency trained emergency physicians. These residency trained physicians will never go to underserved areas where they are needed; they will remain around the cultural centers, commanding higher salaries and enjoying the amenities of city living. The underserved areas will continue to suffer, and have a lack of or diminished physician services.

The newly residency trained doctor will not want to work the long laborious night shifts or odd hours, and most likely will not want to work more than the usual work week when the hospital is in a pinch. The hospital will find itself still turning to even more expensive locums coverage. This is what ACEP and its companions want because who will most likely be the locums owner and provider? Probably the same residency trained doctors group or some similar type of arrangement.

These are some of the reasons that ACEP and its companions want to rule out ABPS, family, and internal medicine doctors from working in emergency departments. I don’t think it has a lot to do with training or the ability to work an emergency department at all. I don’t think you can tell a hospital administrator with confidence that a doctor just out of residency is more capable of working in an emergency department than a 20-year veteran emergency physician who has worked more than 4,000 hours a year for 20 years in an emergency department.

I have nothing against residency training. If a practitioner knows when he finishes medical school that emergency medicine is the field that he wants to pursue, then go into an emergency medicine residency. But, like most things in life, nothing is perfect. We finish medical school, chose our paths, and for whatever reasons decide that something else may be more attractive than what we chose. So maybe we find one of those small hospitals that will allow doctors residency trained in something other than emergency medicine to work in the emergency department because of need and because they cannot find a board certified residency trained emergency physician at any price who wants to come to Timbuktu to practice mistake-free medicine because we all know residency trained doctors never get sued and never make mistakes.

No one in emergency medicine wants a practice track, but it is still needed, and as long as there are not enough residency trained physicians to cover our emergency departments, some hospitals will have to use internists or family practitioners to cover their departments. The way to ensure that these physicians have the knowledge of emergency medicine is to offer them certification. If a family practitioner or internist wants to work in the emergency department, ABPS or some other entity should offer testing before the doctor ever works in the emergency department. Maybe an airway clinic or some type of anesthesia course also should be offered prior to the physician working in the emergency department. This would better serve the public and better ensure patient safety than fighting over certification, which only boils down to a fight over money.

My message to ACEP is this: When you can tell me that state regulations will allow your residency trained doctors to drop their malpractice insurance because they are so perfect, I will believe that only residency trained doctors should be in emergency departments. We all have to carry malpractice, which means that the public doesn’t believe in any of us, so to better protect them and ourselves, why don’t we unite and develop solutions that include all of us? There is enough room at the table; visits keep going up, and people keep coming. Let’s quit acting like wolves and pigs, and act like humans who can talk and work things out, and come up with solutions instead these turf battles.

John Stanton, DO
Horsham, PA

COMMENT:

“I have never seen this type of idiocy in any profession other than medicine.”

Thank you for your letter, Dr. Stanton. I would venture to add that not only has “this type of idiocy” not been seen in any other profession except medicine, but the level of  abuse and vituperation hurled mainly by AAEM (see Dr. Scaletta’s Nasty Comments)  over the decades since ABEM  prematurely and mistakenly closed its practice track, even in medicine, can only be found in the specialty of Emergency Medicine, much to its eternal shame.

“Turf wars” occur between specialties on a regular basis. Even now, radiologists and emergency physicians battle over who is qualified to do ultrasounds in the ER;  plastic surgeons, ENTs, and ophthalmologists argue over who is best qualified to do eye lifts; Dermatologists and cosmetic surgeons maintain that they should be the only ones who should do botox and restylane injections, the list is endless.

However,  most of these other “turf wars” have been conducted in semi-civilized, collegial discourse between specialty groups without resorting to demeaning, occasionally libelous speech which has been the hallmark of the rhetoric of AAEM and its minions.

And instead of healing the rift and seeking solutions for ALL ER physicians, not just the ABEM certified,  ACEP has exacerbated the divide by siding with AAEM, making non-EM residency trained physicians like Dr. Stanton even more disenfranchised. This is a failure of leadership and policy that can only be described as tragic.

Fortunately, the American Academy of Family Physicians has stepped into the void left by ACEP and has been more proactive in advocating for the significant number of its members who do practice Emergency Medicine. They also have enough foresight to offer solutions to the EP shortage in the rural areas by sanctioning EM fellowships, which of course, the EM leadership is fighting tooth and nail.  (see: EM Fellowships for FPs: Bane or Boon?)

Let us hope that the bullying tactics of AAEM and ACEP do not win the day. The only way to combat this would be to support ABPS and AAFP in its efforts, such as during the Texas Medical Board meeting.

LINKS:

GruntDoc

“Affirmed”!

and with that, the NY Appellate Court, seemingly sealed the dismissal of ABPS’s suit against NY-DOH, forcing a possible showdown before the U.S. Supreme Court.

The Appellate Court, gave short shrift to the strong arguments made by ABPS’s lawyer, Mr. Michael Sussman, easily finding for NY State, without reasoning or gravitas.  

Not that the Court needed a reason. You see, actions by this or any state, wherein the regulation(s) involve health education and welfare and not race, gender or nationality, gets subject to a legal analysis called, “rational basis”. And DW wants you to know that “rational” is used loosely, we mean really loosely, we mean even, irrationally.

Here is what occurred;

(1) New York has a physician website that lists doctors as emergency medicine board certified IF they did a residency in emergency medicine,  no problem there,

(2) an organization called ABEM [The American Board of Emergency Medicine, owned by the American Medical Association] lobbied New York to list MDs with its certification as board certified, whether or not they had done a residency in emergency medicine.

(3) the ABPS [American Board of Physician Specialties, certifies experienced ER doctors who have done residencies such as surgery, family practice and internal medicine AND have at least 5 years experience in emergency medicine practice, not owned by the AMA, having a patient first position] sued  because except for the emergency medicine residency requirement, their ER doctors meet and exceed the criteria, permitting the ABEM non ER residency trained to be able to advertise themselves as board certified.

(4) ABPS contended that if the ABEM/AMA doctor did not do a residency s/he should not be listed on the State’s website following the rule. But that if such a doctor certified by its competitor could be listed, then ABPS doctors should be listed as well.

(5) It is even simpler, ABPS said there should be a site where all ER docs should be listed, and in fact the State could list the certifying board, and whether or not an emergency medicine residency was done. ABPS believes that the best ER docs are residency trained in a relevant specialty and experienced with more than five years practice and does not accept the AMA tenet that three (3) years of emergency medicine is enough. Some hospitals agree and have even added another 4th year. However, that still does not trump greater than 5 years of experience.

 A simple and rational argument; if the rule says, you have to be emergency medicine trained to be board certified in new york, ABPS argued, then why are non emergency trained ER docs listed as certified. Was it simply because they had grandfathered certification by the AMA?

All that seems simple enough. And yet, the courts in New York, ruled against the ABPS    essentially aiding and abetting the business of the AMA/ABEM, on the basis that New York’s action was “rational”- The sort of irrational technicality that only lawyers and judges can understand. the sort of irrationality that allows criminals to get away with their crime(s).

DW asks, when did New York get into the business of aiding and abetting bad actors who seek to destroy competitor organizations with complete disregard for patient welfare issues, such as adequate access to Emergency Care?

DW has learned that there are hospitals in upstate New York, that don’t have and cannot recruit any ER doctors. Moreover, superior ABPS ER physicians are excluded from the Emergency Medicine workforce because of the AMA’s predatory action; now assisted by the state.  

DW wonders who the Court would prefer seeing if they had an emergency: a physician trained in a relevant specialty e.g. surgery, medicine, family practice, anesthesiology, pediatrics, with at least 5 years experience as an ER attending such as the ABPS certified physicians; OR, a physician who only completed a three (3) year residency in emergency medicine but was certified by the ABEM/AMA. If the court is confused, ask the patients in Upstate New York, or indeed throughout the state.

PATIENTS PREFER EXPERIENCED AND EXPERT PHYSICIANS, THAT’S JUST COMMON SENSE. 
Unfortunately, as we all know “common sense” isn’t so common, and as it turns out, in NY state, “rational” isn’t rational either.
INCIDENTALLY, A RECENT NATIONAL STUDY HAS SHOWN THAT EM RESIDENCY TRAINING DOES NOT IMPROVE QUALITY OF CARE.  (see EM Residency Training and Quality Measures)

What were the judges thinking? CLEARLY, THEY WEREN’T THINKING FOR THEMSELVES BUT MERELY CHOSE TO LISTEN TO AMA/ABEM TO THE DETRIMENT OF THE PEOPLE OF NEW YORK.