One wonders what they were thinking during the interview.
Archive for March, 2007
One wonders what they were thinking during the interview.
This may not serve them so well now that Malpractice attorneys are developing strategies to take down attractive physicians. (See post on Dr. Flea)– DW
Phenotypic differences between male physicians, surgeons, and film stars: comparative study
Antoni Trilla, director of preventive medicine and epidemiology unit, Marta Aymerich, consultant, haemopathology unit, Antonio M Lacy, consultant, general and digestive tract surgery unit, Maria J Bertran, specialist, preventive medicine and epidemiology unit
1 Hospital Clinic, University of Barcelona, 08036 Barcelona, Spain
Objectives To test the hypothesis that, on average, male surgeons are taller and better looking than male physicians, and to compare both sets of doctors with film stars who play doctors on screen.
Design Comparative study.
Setting Typical university hospital in Spain, located in Barcelona and not in a sleepy backwater.
Participants Random sample of 12 surgeons and 12 physicians plus 4 external controls (film stars who play doctors), matched by age (50s) and sex (all male).
Interventions An independent committee (all female) evaluated the “good looking score” (range 1-7).
Main outcome measures Height (cm) and points on the good looking score.
Results Surgeons were significantly taller than physicians (mean height 179.4 v 172.6 cm; P=0.01). Controls had significantly higher good looking scores than surgeons (mean score 5.96 v 4.39; difference between means 1.57, 95% confidence interval 0.69 to 2.45; P=0.013) and physicians (5.96 v 3.65; 2.31, 1.58 to 3.04; P=0.003). Surgeons had significantly higher good looking scores than physicians (4.39 v 3.65; 0.74; 0.25 to 1.23; P=0.010).
Conclusions Male surgeons are taller and better looking than physicians, but film stars who play doctors on screen are better looking than both these groups of doctors. Whether these phenotypic differences are genetic or environmental is unclear.
We finished our medical training at the University of Barcelona more than 25 years ago, and have enjoyed our work ever since. At medical school we noted certain differences between male trainees who selected either surgery or medicine as their specialty. The tallest and most handsome male students were more likely to go for surgery, and the shortest (and perhaps not so good looking) ones were more likely to become physicians (including doctors of internal medicine and its subspecialties).
Now, after all these years we hypothesise that, on average, surgeons are taller and better looking than physicians. We conducted a comparative study to test this hypothesis.
We selected a random sample of senior staff surgeons and physicians working at the University of Barcelona Hospital Clinic (a 700 bed public hospital), matched by age (52 ±7 years) and sex (all men), from the staff payroll of the surgical and medical departments. We contacted all eligible participants by email. If they agreed to participate, their height (in cm) was recorded and they were asked to submit a digital picture. Age (in years) was registered and checked against that recorded in the payroll database. The external controls were four well known film stars, mostly in their 50s—Harrison Ford as Dr Richard Kimble (a neurosurgeon in the film The Fugitive), George Clooney as Dr Doug Ross (a paediatrician in the television series ER), Patrick Dempsey as Dr Derek Shepherd (a surgeon in the television series Grey’s Anatomy), and Hugh Laurie as Dr Gregory House (a nephrologist and infectious disease specialist in the television series House).
We randomly organised the pictures of all surgeons, physicians, and external controls and showed them to an independent group of eight female observers—three doctors and five nurses from our hospital. All observers were in the same age group as the participants (no further checking of this information was attempted). We decided to avoid (for the time being) male observers, because of potential bias. Observers used the “good looking score” to classify each participant. This score measures the degree of handsomeness on a seven point Likert scale (1, ugly; 7, very good looking).
We discarded the highest and lowest score (outliers) for each participant and used the six remaining scores for our study. Mean scores, differences in means with 95% confidence intervals, and standard deviations were used to compare the three groups. We used the standard t test to compare age and the non-parametric (Mann-Whitney U) test to compare height and mean good looking scores.
We contacted 14 surgeons and 16 physicians (24 surgeons and 38 physicians were eligible). Only two surgeons and two physicians did not answer the questionnaire or send a picture (their out of office auto reply was switched on). Two additional physicians were dropped from the final analysis because of the poor quality (technical, of course) of their pictures. The final analysis therefore comprised 12 physicians and 12 surgeons plus four external controls.
The mean age of physicians was 50.6 years (SD 4.02) and of surgeons 51.1 years (SD 4.11) (P=0.76). The mean height of physicians was 172.6 cm (95% confidence interval 170.2 to 175.4) and of surgeons 179.4 cm (175.1 to 184.0) (P=0.01).
Film stars (external controls) had significantly higher good looking scores than surgeons (5.96 v 4.39; difference between means 1.57, 95% confidence interval 0.69 to 2.45; P=0.013) and physicians (5.96 v 3.65; 2.31, 1.58 to 3.04; P=0.003). Surgeons had statistically significantly higher good looking scores than physicians (4.39 v 3.65; 0.74, 0.25 to 1.23; P=0.010). We found small, non-significant differences between film stars who played either surgeons or physicians. Incidentally, we noted a higher proportion of baldness (surrogate marker) among physicians.
The figure shows a control, a surgeon, and a physician from our study (the physician and surgeon are by chance authors of this study) to provide a snap shot summary of the main study findings.
We did not make individual results public. However, widespread rumours, discussions, polls, and illegal bets arose throughout the institution as a by-product of our study. If they requested, participants were privately told about their personal score compared with the average score of the relevant group.
Our study shows that, on average, senior male surgeons are significantly taller and better looking than senior male physicians. It also shows that film stars who play doctors are significantly better looking than real surgeons and physicians.
Differences between surgeons and physicians
Perhaps because of their training, surgeons have a different attitude and approach to the practice of medicine compared with physicians. The surgeon’s image is that of competence, trust, expertise, and compassion.1 Surgeons are the only doctors who practise what has been called “confidence based medicine,” which is based on boldness.2 They are often practical and fast acting, and they exert tight control on their natural turf—the operating theatre. Being taller and better looking has several evolutionary advantages for surgeons. Their extra height makes them more likely to be masters and commanders, and gives them a better view of the operating room, including the patient lying on the table. Also, as the senior male surgeon is normally surrounded by junior surgical staff, training fellows, nurses, anaesthetists, and the like, his height and appearance make him easily identifiable as their leader.
How do surgeons become taller and better looking than physicians?
There are several potential explanations for the phenotypic changes between surgeons and physicians. Firstly, surgeons spend a lot of time in operating rooms, which are cleaner, cooler, and have a higher oxygen content than the average medical ward, where physicians spend most of their time. Furthermore, surgeons protect (but not always properly) their faces with surgical masks, a barrier to facial microtrauma, and perhaps an effective anti-ageing device (which deserves further testing). They often wear clog-type shoes, a confounding factor that adds 2-3 cm to their perceived height. The incidental finding that fewer surgeons are bald might be related to these environmental conditions and to the use of surgical caps.
In contrast, senior physicians are surrounded by fewer people in their habitat (the patient’s bedside and the office), and they therefore have less need to be easily identified or spotted by families and nurses in the middle of a swarm. Physicians tend to hang heavy stethoscopes around their necks, which bows their heads forward and reduces their perceived height. They also complain of a (clearly abnormal) need to endlessly update their knowledge in accordance with the current evidence based approach to medicine by reading and studying heaps of medical journals; this overload of information further grinds them down. Although a prospective study found that doctor’s white coats decrease in weight with increasing seniority, no significant difference was found between the mean weight of physicians’ coats and surgeons’ coats (1.4 v 1.5 kg).3
Limitations and future studies
Firstly, we did not independently assess the height of the study subjects. However, we trust in their honesty and believe that any potential bias would always point in the same direction, as people tend to overestimate rather than underestimate their height. Secondly, we did not check if the submitted photographs had been improved using the latest technology. The members of the evaluating committee know all the study subjects well, and would easily have spotted any gross attempt at cheating (such as submitting photographs taken when the subject was younger or photographs of another person). Thirdly, the evaluation process of the good looking score is subjective, but we have no reliable alternative. The best known alternative published in the literature (asking a mirror, “Mirror, mirror on the wall, who is the fairest of them all?”) works only for queens, a notable shortcoming of this test.4 Although it is widely known that the mirror always spoke the truth, at present we do not have access to this device (not currently supplied by the Spanish national health system).
Further studies are needed to assess whether our findings also apply to junior male surgeons and physicians, as well as to senior and junior female staff. Currently the number of female surgeons in their 50s at our institution is small, and we cannot enrol enough study subjects, a situation that will change no doubt over the next five to 10 years. We believe also that a non-crossover design deserves further testing (good looking score of men evaluated by men and a similar system for women).
Male surgeons are taller and better looking than physicians, but whether these differences are genetic or environmental is unclear. However, most surgeons and physicians are pleased with their career choices and even with their looks (personal communications).
Contributors: All authors designed the study. MA and MJB designed the good looking score. AT and AML are guarantors.
Competing interests: AT is a physician and AML is a surgeon. AT and MA have been happily married for 25 years. MA’s good looking score for AT was not requested to avoid any problems at home for Christmas.
Ethical approval: Submitted to the institutional review board (IRB) but transferred for approval by the institutional beauty review (IBR), an ad hoc subcommittee of our institution.
1. Rowland PA, Coe NPW, Burchard KW, Pricolo VE. Factors affecting the professional image of physicians. Curr Surg 2005;62:214-6.[CrossRef][Medline]
2. Isaacs D, Fitzgerald D. Seven alternatives to evidence based medicine. BMJ 1999;319:1618.[F
3. Gordon PM, Keohane SG, Herd RM. White coat effects. BMJ 1995;311:1704.
4. Wikipedia. Snow White. http://en.wikipedia.org/wiki/Snow_White.
(Thanks to Leave No Trace for the tip)
Interview with Harvard physician and New Yorker author Dr. Jerome Groopman, author of “How Doctors Think”
as heard on NPR Morning Edition, March 26, 2007
Doctors Shoulder Mounting Insurance Burdens
by Joanne Silberner
“Somebody’s got to do it. Who else is going to advocate for these people? I’m stuck being a secretary more than a doctor sometimes.”
Dr. Rebecca Jaffe, Family Physician
Physician participation in managed care (health insurance, HMO and PPO) sharply increased between the late 1980s and the late 1990s. In that same time, the percentage of physician income from health insurance providers more than doubled.
· Behind Dr. Rebecca Jaffe’s desk hangs a large black-and-white framed photo.
“That’s me on my third birthday, sitting on my grandmother’s step,” Jaffe says, “with my junior doctor kit.”
When she was younger, Jaffe says, she wanted to grow up to be just like the doctor who took care of her family.
She didn’t know that her life would be very different from that of her family’s doctor. She is a family physician, practicing in Wilmington, Del. But she increasingly struggles to spend quality time with her patients as disputes with insurance companies demand more of her attention.
For the first time in nearly two decades, efforts to improve the health care system are back on the national agenda. But even since former President Bill Clinton tried to overhaul the system, practicing medicine has greatly changed.
As Jaffe sees it, “insurance hopes to keep people well until they’re 65 and on Medicare.” After that, she says, it becomes somebody else’s problem.
Because insurance companies watch costs aggressively, Jaffe says she has to fight to get her patients the care they need. On two occasions, insurers told her they would pay less for an immunization than it would cost her to buy the vaccine, let alone administer it.The insurance company told her to make up the cost by seeing more patients.
“I just felt that was so wrong,” Jaffe says. She believes that good medical care takes time.
for full article and podcast, go to NPR Morning Edition March 26, 2007
The post below was circulated to me anonymously. Yes, it’s a rant but I think it is extremely pertinent to the discussion and would like to share it with you all. I agree with many of the points made, (except for the FMGs):
Tom Scaletta, MD FAAEM: …”For instance, it could be required that physicians are board certified (or prepared) in emergency medicine.”
MY TOP TEN LIST:
1) What about the fact that only about half the ER docs are EM-RT (in spite of HUGE increases in our EM residency slots and programs) ?
2) What about the fact that ‘MORE THAN HALF’ the ERs in the country are covered with non-EM-RT docs ? (because we don’t train for, and we cannot interest the new grads in working in the trenches, and we don’t have ANY solutions to discuss) ?
3) What about the fact that 1/3 of the resident in the country are FMGs already ?
4) Where do we get these residents to fill all those forth coming (not really) NEW GME slots ?
(does medicare fund this…someone should just tell them we need more money…I think they will just write us a check, because health care has been so thrifty and cost effective
5) Where do we get the spots in medical school to teach them ? (AAMC says we need a 30-40% increase across the board, maybe more in states likeTexas and Florida)
6) What about the fact that already the Number 1 and Number 2 schools filling residency slots are Caribbean schools ? (St George’s Univ and Ross Univ…Number 3 Illinois…) (AAMC data)
7) Why don’t we just STEAL the medical students going into Internal medicine
and Family Practice ? ( it doesn’t matter that they have a crisis too and want more GME slots and are filling about half their classes with US grads ALREADY—hey we should look into getting more docs to leave their county and practice here–who cares about their country
8 ) Where do we get the college grads interested in Medical School ? (med school deans say there are less than 20% quality applicants out there to increase it to, not the 30-40% AAMC wants)
9) What about the fact that the med school deans say it will take 15 years before we see the first grad out of residency ?
and the MOST IMPORTANT OF ALL
10) The Lawyers, Insurance companies, Chiropractors, Nurse Practioners, Optometrist, Psychologist, Physical Therapist, Acupuncturist are just jumping for joy that we cannot “COME TOGETHER” (great slogan I heard somewhere). That we spend time and money fighting WITH EACH OTHER in Florida and other places, to make our product look better, to make more money, to increase the cost of healthcare.
Because the Nurse Practioners in Texas only have one issue this year….increased scope of
practice…..and the Optometrist have only one issue this year….increased scope of practice. and we should have 67 from the IOM report. But no, apparently THIS is a priority issue. I am sure our patients would just love to hear about how we smart doctors are looking out for ourselves, oops I mean “their safety”.
If this is such an important SAFETY issue, perhaps we should just close half of the already overwhelmed ERs in the country seeing 11% more patients in the last 2 years (while gearing up for the next Bioterrorism Event), because we don’t have a better “solution”. ”
“We must all hang together, or assuredly we shall all hang separately.” -Ben Franklin
from EM News, March 2007 issue:
AAPS SUES NY-DOH OVER BOARD CERTIFICATION ISSUE
article by Anne Scheck
A lawsuit filed against the New York Department of Health by the American Association of Physician Specialists (AAPS) alleges that the state is illegally prohibiting physicians certified by its companion board from listing themselves as board certified on the Internet.
Though no one involved would say whether this is the first legal battle over the legitimacy of Internet postings on physicans- representatives of the accused public agency said they can not comment- the AAPS attorney who filed the case said it represents an important attempt to guarantee the right to display credentials in a public way.
Before filing the suit, AAPS’s certification board, the American Board of Physician Specialties (ABPS) asked the New York Department of Health (DOH) to acknowledge ABPS certification so its physicians can promote themselves as board certified specialists on the DOH’s widely used web site, said Michael Sussman, the attorney representing the AAPS. The complaint is an attempt by AAPS to “level the playing field”, he said, and it singles out emergency medicine in particular.
More than 100 physicians across the state have ABPS-approved specialty titles that they should be able to list on the web site, “yet they are prohibited from doing so,” he said. The reasons were “explicitly’ based more on the subjective view of the AAPS and the ABPS by existing traditional medical organizations rather than on an objective evaluation of the facts pertaining to the ABPS certification process, according to Mr. Sussman.
For full article, click on:
EM News March 2007
Things keep getting “interestinger and interestinger” to paraphrase Alice in Wonderland. As mentioned in my previous post, there is currently a bill being pushed by the Florida ACEP chapter in the Florida legislature which states the following:
A physician licensed under this
chapter may not hold himself or herself out as a
board-certified specialist unless the physician has received
formal recognition as a specialist from a specialty board of
the American Board of Medical Specialties or other recognizing
agency approved by the board which requires completion of an
approved residency or fellowship training program from the
Accreditation Council for Graduate Medical Education in the
specialty of certification.
If this bill passes, it means that ONLY physicians who underwent ABMS approved residency/ fellowship training in a specialty can say that they are board-certified in that specialty. This excludes all the doctors who were “grandfathered” in relatively new specialties which, until recently did not have residency/ fellowship training such as Emergency Medicine, Pediatric Emergency Medicine, Pain Medicine, Hospice and Palliative Medicine, and Sports Medicine, among others. Isn’t it ironic that of all states, Florida, is being “anti-grandfather”?
The bill also wants to exclude all the physicians who are certified by the American Board of Preventive Medicine, the American Board of Pain Management, and the American Board of Facial Plastic Reconstructive Surgery all of whom allow non-specialty trained physicians to be certified, not to mention all the BCEM certified emergency room physicians who are not allowed to take the ABMS approved ABEM exams (see previous posts).
Board certification status is a big deal since it affects the ability of a physician to obtain hospital privileges, be included in the network of health insurance companies, and significantly affects compensation.
So, one may ask, what is the real purpose of this bill? Of what conceivable use is it other than to limit patient access to specialists, possibly create an artificial physician shortage in certain specialties, and tick off a lot of doctors across a wide range of specialties? Those are questions to ask ACEP and the Florida legislation.
If you live or work in Florida and this makes no sense to you, write to your state representative and express your opinion. If you really want to get involved, contact ABPS or USAEM (see links below).Groups supporting both sides of the issue will be rallying at the Florida legislature on March 14.
Make your voice heard.
Emergency Medicine News: Volume 28(11) November 2006 pp 1,30,36
ACEP, AAEM Defeat AAPS Bid for Recognition in North Carolina
SoRelle, Ruth MPH
The American Academy of Emergency Medicine and the American College of Emergency Physicians teamed up in July with other professional medical groups to defeat an attempt by the American Board of Physician Specialties, the certifying arm of the American Association of Physician Specialists, to be recognized as a board certifying agency in North Carolina.
The North Carolina Medical Board refused the ABPS request, but has yet to issue a pubic reason for its decision. Under the 10-year rule, physicians seeking licensure in the state who meet all other requirements can, instead of taking a new test, prove their competence by having certification or re-certification from a specialty board recognized by the ABMS or the AOA or certification or re-certification with added qualifications from a specialty or subspecialty board recognized by the ABMS or AOA or completion of formal postgraduate medical education.
Basically, ABPS was seeking to get that same sort of recognition, said Todd Brosus, an attorney with the North Carolina Medical Board. Mr. Brosus said the board plans to issue its rationale for denying the request soon.
Florida’s medical board accepted the certifying arm of AAPS as a certifying body in 2002 and refused to change that rule in 2003 when petitioned by the Florida Medical Association to reconsider its stance. A later attempt to have the board’s rule made into law failed. After that, AAEM began monitoring every state medical board for such actions, said Tom Scaletta, MD, the group’s president.
We sent them a letter asking that they let us know when there is a request from AAPS, he said. It paid off in North Carolina. The board let us know that there had been a letter requesting consideration of AAPS.
That letter prompted action from AAEM, ACEP, the Society for Academic Emergency Medicine, and other organizations, said Dr. Scaletta, who said many groups sent letters to the North Carolina board. AAEM asked Howard Blumstein, MD, the group’s secretary-treasurer, to testify.
It was pretty straightforward, said Dr. Scaletta. We explained to them that we don’t want a board that doesn’t require emergency medicine residency training accepted as a certifying board in North Carolina.
He said AAPS created another avenue for gaining board certification in emergency medicine and other specialties for those who applied after the practice track closed. That route closed in 1989 after 10 years of warning, said Dr. Scaletta.
Vivek Tayal, MD, the president of the North Carolina College of Emergency Physicians, also testified against the AAPS request after being alerted by officials from the American College of Emergency Physicians. Both he and Otto Rogers, MD, another NCEP member, told the North Carolina board that while the practice track once might have been an acceptable method of training, it is no longer.
Dr. Roger’s testimony was particularly effective because he was practice-track trained, said Dr. Tayal. His testimony suggested that emergency medicine is too sophisticated and complicated to just go through the practice track.
Representatives of AAPS disagreed with that characterization and with the North Carolina decision. They expressed dismay that the North Carolina board had yet to give them a formal reason for the denial, which they received during the July meeting.
Robert Cerrato, DO, the vice chairman of the group, said many members of the AAPS staff presented evidence to the board. There was a lot of Q&A, he said. I thought there was a favorable exchange, and they never gave us any criteria for the rejection.
Dr. Cerrato added that AAPS’ entry into the board certification field represents a threat to the American Board of Medical Specialties, the most accepted and longest-lived board certification agency, which requires residency training as well as a test for its certification. I’ve been in medicine 20 years, he said. When I started, it [board certification] was not needed. Now it is difficult to practice without it.
We hear about physician shortages, said Dr. Cerrato. If they had the public interest at heart, they would not do anything to block other well-trained physicians from getting into the system. The bottom line is that board certification is required for emergency physicians to be employed. That’s a problem.
ABPS and its emergency medicine arm, the Board of Certification in Emergency Medicine (BCEM), do not require emergency physicians to complete an emergency medicine residency. Instead, according to the eligibility requirements on the ABPS web site, physicians can:
▪ Complete a residency in anesthesiology or a primary care specialty, or
▪ Be certified in a primary care specialty or anesthesiology by the ABPS, ABMS, or AOA boards of certification, or
▪ Complete a 12- or 24-month emergency medicine graduate training program approved by BCEM and have practiced emergency medicine full-time for five years, accumulating at least 7,000 hours of practice. The graduate course cannot be substituted for a primary care or anesthesiology residency.
It is the failure to require residency training and board certification in emergency medicine that concerns them, said members of AAEM and ACEP. Dr. Cerrato of the AAPS noted that some emergency physicians who are members of ACEP did not complete residency training, and that some were grandfathered in under the practice track provision that ended in 1989.
He said AAEM and ACEP now oppose the practice track as a route to board certification, while AAPS holds that a practice track policy is a good one. In actuality, isn’t that what residency training is? he said. Isn’t it on-the-job training? He disputed the notion that residencies are more highly supervised now than they were in the past. On-the-job training is on-the-job training, he said.
Lewis Marshall, MD, a former president of AAPS, said his group closed eligibility for board certification without a full residency in 1999. Physicians who work in the emergency department have dedicated themselves to providing emergency care, he said. Physicians who train in internal medicine and family practice have shown a commitment by submitting themselves to a test that shows their level of skill in specific areas of emergency medicine practice. He said when ABEM closed the practice track in 1988, they closed out a lot of people who had been practicing emergency medicine. AAPS then became the only certifying organization that would permit those with primary care residency [or certification] and five years’ practice to prove to themselves and their patients that they had a commitment to provide quality emergency care.
The group has not yet decided where it goes from here in North Carolina, said attorney James Wilson, JD, who represented the firm. AAPS members said they might seek similar recognition in states where it is an issue. In many states, it makes no difference, said Dr. Cerrato. They don’t have these kinds of rules. Many medical boards do not require board certification, but some have rules about the training of those who run advertisements in which they state their board certification.
Dr. Tayal noted that some members of his state’s organization have followed the practice track, and they are good physicians. We value the service they provide to the society and medical system, but we are not going to accept their certification.
Dr. Scaletta said he expects AAPS to continue to seek recognition. This is definitely a tenacious group, he said. They are really pushing because for them it’s important. But he said using a backdoor route to enter emergency medicine is not something that should be condoned by mainstream medicine.
He compared it with licensing airline pilots. When you fly somewhere, you have faith that the pilot is credentialed by the organization that does that. You have faith that someone is not learning on the job. The public has the same faith in emergency medicine. Patients presume they are being taken care of by board certified physicians.
ABPS Requirements for Emergency Medicine Board Certification
▪ Conform with the ABPS Code of Ethics, be known as an ethical professional, be active in emergency medicine, and be a member in good standing with AAPS.
▪ Be a graduate of a recognized college of medicine confirmed by a copy of an allopathic/osteopathic degree or a letter of verification. Foreign medical school graduates must submit an English transcription of the document and a copy of the ECFMG Certificate.
▪ Have a valid, unrestricted license to practice medicine in the U.S.
▪ Be certified as a provider in ACLS, ATLS, and PALS.
▪ Complete residency training in an ACGME- or AOA-approved program acceptable to BCEM, including substantial, identifiable training in emergency medicine as determined by BCEM and approved by ABPS.
▪ Complete an ACGME- or AOA-accredited emergency medicine residency.
▪ Practice emergency medicine full-time for five years (minimum of 7,000 hours) and complete an ACGME- or AOA-accredited primary care or anesthesiology residency or be certified in a primary care specialty or anesthesiology by an ABPS-, ABMS-, or AOA-recognized board of certification.
▪ Complete either 12- or 24-month emergency medicine graduate training approved by BCEM. Physicians completing a 12-month program must have practiced emergency medicine full-time for an additional 12 months before or after completing the training. (Full-time practice is defined by BCEM as at least 1,400 hours per 12-month period.)
▪ Verified staff privileges by the administrator of each hospital that privileges are in good standing.
▪ Submit 10 documented emergency medicine cases for which the physician had the lead management role.