Archive for October, 2007

(I am posting this “editorial” from the Floria ACEP EM Pulse mainly because when other physicians tried to respond to this piece in writing, they were informed that their letters would not be published. Therefore, in the interest of free speech and debate, I am offering this space as a forum to discuss the issues. Note: I put the phrases I found interesting in boldface, everything else is Dr. Graber’s.)

from EMpulse September / October 2007
THE EDITOR’S EMERGENCIES
Like it Or Not, The Future is Emergency Medicine Residency Training
by Mylissa Graber, MD, FACEP editor@fcep.org
VP, Florida College of Emergency Physicians

I find it so sad that there are still people that think that someone does not need to be residency trained in emergency medicine in order to begin a career in emergency medicine in today’s day and age. Not only do some physicians think that way, but they actively pursue
legislation to always keep that door open and belittle what all of us have worked so hard to develop: a quality,well-trained emergency medicine specialist, who has been rigorously drilled and tested on a specific skill set that makes them capable of working extremely effectively
in any emergency department, and ready for any emergency situation. Not only do these others continue to fight this, but they do it with half truths about what we are doing and what we are trying to accomplish.

As you all should know, this past year we submitted a bill in the state of Florida to require specialty-specific residency training in order to be recognized as Board Certified in the state of Florida on a go-forward basis,meaning that anyone who has already been recognized
as board certified would still be so, but that from this point on we will close the door to those training in other fields to pursue an emergency medicine career. ABEM closed its doors 20 years ago. ACEP closed its doors eight years ago, and still, even with that, we decided in
Florida that anyone recognized up to now, 2007 or when resubmitted next year in 2008, could still be recognized, but not past that. The bill specifically states that the Florida Board of Medicine could only recognize organizations that require emergency medicine residency training
to enter the specialty as of this year, which means that all AAPS would really have to do to be recognized and end this entire ridiculous continued struggle, would be to shut the door for new diplomats to only those who have completed an accredited emergency medicine residency
program. But instead of doing that, they choose to spend thousands and thousands of dollars to “defeat us” and to continue to push state-by-state to forever keep the door open to non-residency-trained physicians entering emergency medicine. Why?

Two sessions ago we attempted to submit this bill, and I met personally with certain key legislators who could pass the bill through, including one who had sponsored the AAPS bill that failed a few years before. Interestingly, when he heard what we were trying to do,
he agreed completely and said he would support us on this. We met with him several times after and he still gave his support. Then a lobbyist for the “other side,” who apparently had been away, and who had some sort of connection to this legislator, resurfaced and the next
thing we knew, the legislator withdrew his support and we were blocked from filing the bill. Why?
Recently I was talking to a colleague I used to work with, who unbeknownst to me is BCEM certified, not ABEM certified. I knew that he was not EM trained by his practice style, but assumed he had grandfathered in to ABEM and he had never told me otherwise until
recently. I had called him about something else and he told me how he heard about the bill I was pushing and that he had received correspondence from AAPS stating that they needed to fight this bill, because it would result in the loss of his job and the end of his career, etc. He
told me he donated several thousand dollars to help them fight this “cause.” Of course, I had a lot to say about that and was furious, especially because this was blatantly
false and I was upset that as a personal friend he never came to me to inquire about what was really going on. I explained to him that the bill we submitted was not retroactive and that anyone recognized or already practicing would be able to continue to do so, that this is only
about board certification and not employment, and that this was about the future workforce of emergency medicine, not the present, and that no one entering emergency medicine today should be residency trained in anything other than emergency medicine. His response: “Oh,
well I agree with you about that. That’s not what they said. Hmm, I will need to talk to them.” I told him he gave a huge amount of money – I wish we could foster that kind of contribution for any of our other issues -against something he didn’t even agree with, because he
was given false information. He told me he was going to follow up with them, but I haven’t heard anything since. So let’s look into this for a moment. Why would an organization rally up such support from their members based on inaccurate information? And why is it that they
require specialty specific residency training for almost every other specialty except emergency medicine? What is it that is driving them so? Well, a few years ago I visited their website and found out some interesting information.

The vast majority of the new diplomats, who sit for their boards, sit for the emergency medicine boards. It would seem that we may be their “cash cow” and we could easily surmise that if they close their doors to only EM residency-trained physicians, they may be losing significant money, so they potentially have a lot at stake financially. Sad, isn’t it, that it may not be about quality after all? Interestingly, I visited the site again, and you can no longer access this information. I guess they were afraid we might catch on. There is also another website bragging about their success at “defeating” the bill that we sponsored and announcing that they are suing the New York Board of Medicine, that thanks to that they can
continue to be recognized and it states on there that this will “open the door for non-ER trained, non-ABEM certified ER physicians to continue their careers and maintain
their livelihood.”

I still do not understand what they are talking about.The physicians who have been so vocal and intricately involved in their activism and responsible for getting the Florida Board of Medicine to recognize them are far from unemployed. In fact, some of them are leaders of the
community and even directors of the ERs, own groups, etc. One I know of who is very vocal is retired, not even practicing anymore. I’m sorry that 20 years ago they missed the deadline for sitting for the ABEM boards or chose not to because they didn’t think it would matter, but there had to be a cut-off somewhere, and the natural attrition of these physicians needs to take place. The doctor who I know is in absolutely no danger of losing his job.

There are non-EM-trained physicians all over the state that are working in emergency departments and have been for 10, 20, 30 years who have very secure jobs, but
emergency medicine has become very complex, so it is inappropriate for physicians currently training in other specialties to use these alternate routes to enter emergency
medicine and call themselves board certified emergency physicians without doing the appropriate emergency medicine training. The learn-on-the-job approach
with no formal supervision or training is not only antiquated, but in today’s day and age potentially harmful and definitely unfair to our patients.
As the non-EM-trained physicians retire, they should naturally be replaced with
residency-trained emergency physicians. The argument that we will never fill all emergency departments with EM-trained physicians is a ridiculous one. More and more programs are opening up and more and more EM trained physicians are entering the field and several that I know personally have left the academic and urban world to go to some of the underserved and less-populated areas to live and practice. Even so, if a physician who is a family practice doctor chooses to work in these areas in the ED, that is fine, but s/he is still a family practice doctor,not an emergency physician and there is no shame in that.
Just don’t misrepresent who you are.
In the same way,when I do a pelvic exam, I do not tell the patient I am a gynecologist, and when I put in a chest tube, I do not say I am a cardiothoracic surgeon. I’m an emergency physician and I am proud of that. You should be proud of your specialty too.
This fight is not over and we will continue to pursue residency training in EM as the only appropriate pathway into emergency medicine today, but it is time for the emergency medicine residency-trained docs to stop sitting on the sidelines and join this fight. We need your
support too. Don’t assume we’re going to fix the problem and that we will naturally prevail. We need to make our voices heard. Contribute to FLACPAC, write articles,
come to EM Days and visit your legislators at home to push this issue. Feel free to contact me and I’ll put you on a list of people who want to help and let you know how you can get involved. We don’t expect you to give thousands of dollars, but every little bit helps. When you
send your checks to FLACPAC, write residency training on the “for” line. We need to spark the same passion for the importance of residency training in emergency medicine board certification as these other physicians have in undermining our progress. Like it or not, residency training
in emergency medicine is the future. It’s just a matter of time.

LINKS:
Response to Florida ACEP: “No Correlation Between Doctors WhoFailed to Meet Standard of Care and Board Certification”

Supply of Board Certified Emergency Physicians Unlikely to Meet Projected Needs Across the US

American Board of Physician Specialties (ABPS)

Disposable Doctors 2: ER docs fight back in NY

Not So Disposable Doctors
Florida to Say, “Bye bye Grandpa!”
Disposable Doctors 1

An ER Doc’s Top Ten List

The Professor’s Last Lecture

Posted: October 3, 2007 by Doc in Mortality, Videos

As physicians, we have seen our share of suffering and death. While we may be able to relieve some of the physical pain that illness brings, we are rarely as adept in helping our patients cope with the emotional and psychological consequences of a devastating illness. To a physician, death signifies failure, even though it is inevitable for all of us.
It is said that the moment when we are faced with our mortality is the moment when our true self is revealed. Professor Pausch, whose story is told below, is all the more extraordinary and inspiring for his grace and serenity. He is a teacher who loves life, teaching, and his students and it is fitting that one of his final acts is to share the ultimate “teachable moment”.

from ABC News:
Randy Pausch, a 46-year-old computer-science professor at Carnegie Mellon University, has terminal cancer and expects to live for just a few more months.

This week, he said goodbye to his students and the Pittsburgh college with one last lecture called “How to Live Your Childhood Dreams,” on his life’s journey and the lessons he’s learned.
The Wall Street Journal called it “the lecture of a lifetime” and those who have seen it have more than agreed.

A beloved professor at Carnegie Mellon, Pausch got a standing ovation from the 400-member audience before he even opened his mouth.

“Make me earn it,” he told them.

No Self-Pity
Pausch, a father of three, talked about his battle with pancreatic cancer. “So in case there is anyone in the room who wandered in and didn’t know my back story, my dad always said, ‘If there is an elephant in the room, introduce him,'” Pausch said in the lecture.

“If you look at my [CT] scan, there are approximately 10 tumors in my liver. The doctors told me I had three to six months of good health left. That was a month ago so you can do the math.”

The diagnosis was a grim reality, but Pausch doesn’t do grim and he doesn’t do self-pity.

“I’ve never understood pity and self-pity as an emotion,” Pausch told Diane Sawyer on “Good Morning America” today. “We have a finite amount of time. Whether short or long, it doesn’t matter. Life is to be lived.”

The lecture is filled with jokes.

“We’re not going to talk about spirituality and religion. Although I will tell you that I have experienced a deathbed conversion. I just bought a Macintosh. … Now I know I’d get 9 percent of the audience with that,” Pausch said.

He also told the audience he was in “phenomenally good health” at the moment and even did a round of one-handed push-ups to prove it.

Patience Rewarded
Pausch said he looked back at family photos and saw that when he was a kid, he was smiling in every picture.

“So what were my childhood dreams? You may not agree with this list, but I was there. Being in zero gravity, playing in the National Football League, authoring an article in the World Book Encyclopedia. I guess you can tell the nerds early,” he said in the lecture.

Though he achieved most of his childhood dreams, Pausch flashed his rejection letters on a screen and talked about career setbacks: “Brick walls are there for a reason. The brick walls aren’t there to keep us out. The brick walls are there to show us how badly we want things.”

Pausch says he’s not afraid of death, but does worry about the process of dying.

“Well the particular way I’m going to die is not going to be particularly pleasant. It will probably be physically uncomfortable and it won’t be an easy thing for my wife and kids to watch,” Pausch told Sawyer. “I think it will be a real challenge to see if I can squeeze the lemons hard enough to still get lemonade the last few weeks.”

But Pausch said in the face of adversity, don’t complain, just work harder. Your patience, he says, will eventually be rewarded.

“You know, life is a gift,” Pausch told Sawyer. “Again, it sounds trite, but if you wait long enough, other people will show you their good side. If there’s anything I’ve [learned] that is absolutely true. Sometimes it takes a lot longer than you might like. But the onus is on you to keep the hope and keep waiting.”

From the Wall Street Journal:

Here is video of Professor Pausch’s full lecture: