Archive for category ACEP Updates
By Alexander M. Rosenau, DO, CPE, FACEP
As we come upon the halfway point of my Presidency, I’d like to offer ACEP members an update and share news about exciting things we’re working on for the coming months. For me, the past six months have been intense, as I’ve connected with individual members, groups, organizations and legislators in concert with our strong Board of Directors, expert staff and amazing volunteer physician members. Dialogue, conflict management for a better result, as well as bringing together the right folks for both the challenges at hand and those just over the horizon are daily activities. I’ve cherished every minute. Emergency physicians enjoy a tremendous relationship with each other, and I know we’ve done some things in the past six months to make our bond even stronger – and to appreciate our past even more. In all things emergency medicine, my mantra is “them is us and us is them,” meaning that the common bond we share is much stronger than the forces tugging at us in disparate directions. When you read this update, please know that I will continue to work hard for you over the next six months, and I welcome any feedback. I hope to see you at our Leadership and Advocacy Conference next month and ACEP14 this fall, and please don’t forget to say, “Hey.”
Report Card Garners Major Media Attention
Although we don’t like the results we saw from the release of the 2014 State-by-State Report Card on Emergency Medicine, an overall grade of D-Plus nationwide could have a positive impact on health care moving forward. Our Report Card fostered many a conversation with state legislators. Media outlets have pointed out what we already knew – that several states don’t have the resources and policies in place to support high-quality emergency care. Stories about the Report Card appeared in major newspapers, including The Washington Post, The Chicago Tribune, The New York Daily News, Forbes, The Huffington Post, The Los Angeles Times, San Francisco Chronicle, The Philadelphia Inquirer, Houston Chronicle and The Seattle Times, to name a few. Along with print stories, nearly 800 broadcast stories aired on news organizations including ABC’s World News Tonight with Diane Sawyer, MSNBC, CNN, Fox News’ Your World with Neil Cavuto, Fox Business News, CNBC’s Kudlow and Kramer, WNBC New York, and Telemundo as well as dozens of local television stations across the country. The estimated audience reach was 72.2 million people. Our dedicated spokespersons will continue to make sure the results of this study resonate nationwide. Keep up with the progress at www.emreportcard.org.
ACEP Working on Several Federal Advocacy Efforts
One of the most critical federal advocacy projects we’re currently working on is the support of H.R. 36/S.961, the “Health Care Safety Net Enhancement Act of 2013,” introduced by my 911 key contact, Rep. Charlie Dent (R-PA) in the House and Sen. Roy Blunt (R-MO) in the Senate. The bill provides medical liability relief for physicians providing care under the EMTALA mandate. The House bill continues to gain support and reached nearly 70 co-sponsors last month. Our advocacy team is working diligently on SGR repeal in concert with a number of allies. Although the CBO rated an SGR fix the most affordable ever, Congress failed to settle the offset funding issue and we didn’t get the permanent fix. The previous work of our Washington office in collaboration with our specialty and AMA allies assured prevention of a seriously damaging 24 percent cut in Medicare reimbursements for one year; also extending dozens of other expiring health care-related provisions. ACEP will continue to work with the AMA and other medical specialty societies to encourage members of Congress to take action this year on the permanent repeal of the SGR. We’ve also been working very closely with the Emergency Medicine Action Fund (EMAF) to address regulatory reform under the Affordable Care Act, including areas related to quality measures reporting and reimbursement.
ACEP Now Launched
When the calendar flipped to 2014, ACEP turned its monthly publication up a notch. We wanted to blend the needs of our membership with an edgy editorial vision related more closely to the world we work in. Beginning with a round-table discussion cover story and a compelling piece on breaking down racial barriers in the ED, the new-look ACEP Now hit mailboxes in mid-January and began receiving rave reviews from ACEP members. I hope you like the direction of our new medical editor-in-chief Kevin Klauer, DO, EJD, FACEP, and our new publishing partner, Wiley Press. The new ACEP Now is not only bigger, it features more incisive opinions, “you are there” real articles regarding our decision making and advice from some of emergency medicine’s most renowned physicians. The news from ACEP and events related to the College will always be a part of the magazine, so none of that has changed. What has changed is the attention to detail and open dialogue when opinions differ on controversial issues. If you haven’t seen ACEP Now lately, grab a copy soon. Your feedback is welcome at www.acepnow.com .
Strategic Plan Taking Shape
In leading the annual Board retreat in December, top-level goals and objectives for the college from now until 2017 were debated, prioritized and built for impact. Goal 1: Care transitions and reform of the health care delivery system continue at full gallup. Goal 2 received particular attention with the formation of the Membership Engagement Task Force, the Membership Bylaws Task Force and the Residency Visit Task Force. Your fellow member leaders of these groups, their Board of Director Liaisons, and assigned top level staff are poised for success in member engagement and satisfaction. Here’s an overview of the Strategic Plan:
Goal 1 – Reform and Improve the Delivery System for Emergency Care
- Objective A – Identify, support, and promote delivery models that provide effective and efficient emergency medical and acute care in different environments.
- Objective B – Promote quality and patient safety, including development and validation of quality measures.
- Objective C – Pursue strategies for ensuring fair payment and practice sustainability.
- Objective D – Pursue solutions for workforce issues that ensure access to high quality emergency care.
- Objective E – Advocate for meaningful liability reform at the state and federal levels.
- Objective F – Communicate the value of emergency medicine as an important component of the health care system.
Goal 2 – Enhance Membership Value and Member Engagement
- Objective A – Increase total membership and transitioning resident retention.
- Objective B – Provide robust educational offerings, including novel delivery methods.
- Objective C – Support member well-being.
- Objective D – Ensure adequate infrastructure to support growth.
Building Bridges and Strengthening Relationships
My other mantra is to connect ACEP with others who share our passion for quality health care. If we build bridges and enhance our synergy with other health care organizations, we benefit and so do our patients. We’re currently working to provide input to ABEM for recognition of Clinical Ultrasound for subspecialty certification. This will improve education, continue to allow Ultrasound use for patient care by all members meeting ACEP guidelines and validate point of care as a reimbursable item. This contributes to our value. Our relationship with CORD continues to grow, as does our joint work with CORD and SAEM in GME matters. EMRA has a new executive director and our relationship with EMRA could not be stronger. We’re proud to announce the recent ACEP/SEMPA Advanced Practice Provider Academy drew rave reviews and more than 300 physician assistant and nurse attendees. I participated as our two organizations penned a new five-year management service contract in New Orleans last month. I directed a new task force be formed to reach out to identify opportunities for collaboration with the Society of Hospitalist Medicine. When it comes to building bridges, there are many organizations whose activities, benchmarks and plans have relevance to us. That is just one reason our executive director, Dean Wilkerson, has been such an asset to our organization for the past decade. We meet by phone at least weekly, communicate via email most days. Your Board members are out and about on a national scale gathering information, forming relationships and honing the judgment that all of you expect your elected leaders to use. I personally appreciate their diplomacy and expert work.
Two Clinical Policies Reviewed
ACEP reviewed two Clinical Policies recently. In response to the Council- and ACEP Board–adopted Amended Resolution 32(13), the “Clinical Policy: Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department” is being reviewed. The Clinical Policies Committee, as per council, accepted comments until March 24. Findings and any recommendations regarding the policy will be reported to the ACEP Board in June. Also, per the resolution, future clinical policies will include a 60-day comment period before finalization. A Clinical Policies Subcommittee of ACEP completed a draft clinical guideline in late March, “Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients with Suspected Acute Non-Traumatic Thoracic Aortic Dissection.” It’s open for comments until May 28, 2014. To view the draft policy and comment form, go to http://www.acep.org/content.aspx?ekfrm=96266. For questions, please contact Rhonda Whitson at email@example.com.
Quality Measures and Reimbursement
ACEP has accepted donated emergency medicine quality measures from other organizations, and we’re developing our own for member benefit (both for CMS incentive and avoidance of CMS penalty). These steps, in addition to our continuing education on reimbursement and coding, add value to your bottom line and salary. We’ve had several recent articles, webinars and a spring conference devoted to Reimbursement and Coding, helping you prepare for reimbursement issues, the eventuality of ICD-10 and PQRS benefits in concert with ABEM.
ACEP’s Official Mobile App Improved
The official ACEP mobile app, an essential resource for members and other emergency care providers, received an upgrade early in 2013 to make navigation easier and to improve the design. The next phase of upgrades is currently being implemented. This includes the addition of several links to education resources from ACEP’s bookstore, audio recordings from the monthly Education on Demand newsletter and a section where emergency medicine news published in ACEP Now can be found. You can also find a secure Member Directory, a personalized Member Guide that reflects your chapter and sections, an events calendar and ACEP’s clinical policies. If you don’t have ACEP’s app on your phone, download it today for iPhone or Android devices.
EMF Continues Endowment Push
Since October, EMF has launched a new logo and continues the momentum of the ACEP $1 million match to bring the endowment to maturity with a corpus of $2.5 million. To help achieve this goal, for every dollar contributed to EMF before June 30, EMF will match it with a contribution of 50 cents toward the endowment. EMF has a new board and a new Strategic Plan. It’s Goals and Objectives are to:
- Goal 1 – Position EMF as the principal sponsor of scientifically rigorous research and education to to improve the care of the acutely ill and injured and policy research that aligns with emergency care priorities
- Goal 2: Increase EMF’s capacity to engage more people in emergency medicine research and award more grants
- Goal 3 – Position EMF as the premier 501(c)(3) emergency medicine foundation
- Goal 4 – Increase EMF revenue to fund more research grants and education projects
Please go to www.emfoundation.org, and make EMF your charity of choice.
Annals Added to eCME Options
In collaboration with ACEP’s online education program, articles from the Annals of Emergency Medicine are being offered as a CME component. As of April 2014, there were 13 Annals-based articles available to members. ACEP looks forward to seeing this educational offering become a robust element of ACEP’s overall online education program. Learn more at www.acep.org/ecme.
Concurrent with the inauguration of the eCME program, Annals announced that it would continue its relationship with long-time publisher, Elsevier. The five-year contract runs through December 2018, and provides a solid and stable financial basis for journal revenues. The contract provides a generous editorial office stipend along with a guaranteed minimum royalty, enabling Annals to contribute substantially toward the overall financial success of the College.
ACEP Continues to Add Value, Enhance Image
The continued strength of our specialty requires us to do some heavy lifting in areas such as keeping prudent layperson as a recognized part of the ACA, working toward an SGR fix and changing perception about the cost of emergency care. Working together, we will make progress. As a result, our place in the House of Medicine will be enhanced. And we’re building strong connections with others while providing service to our chapters as they protect the interests of our members. Chapter efforts in Washington state and most recently in Virginia underscore the need for our teamwork. We believe that Steve Stack will become the AMA’s first ever Emergency Physician President. We have a real chance for the AMA to continue its re-invigoration with a clear view of EM’s contribution to the house of medicine because of his upcoming service. If you have any membership dollars available in your professional budget, I hope you consider making this year one in which you might become an AMA member to bolster our ACEP delegation at the AMA. There are certain things that are more do-able when we have a strong delegation within the AMA, whether advancing our cause within the house of medicine or in our negotiations at the RUC.
Spring Conferences in Full Swing, LAC Coming Up
ACEP’s busy spring conference lineup began in February with the Reimbursement and Coding Conferences in New Orleans. With the upcoming changes in coding and the implementation of the Affordable Care Act, payment topics have become even more popular and necessary. More than 200 emergency physicians participated in the February 2014 conference. Your next chance to brush up on your knowledge in this area is March 2015 when the R/C Conferences move to Las Vegas.
The 2014 Advanced Pediatric Emergency Medicine Assembly was held in New York City in March and drew more than 550 four-day registrants. This is the highest number in four years.
ACEP’s newest offering, the Advanced Practice Provider (APP) Academy, recently wrapped up. More than 300 attendees received a crash course in emergency department essentials. Held in conjunction with SEMPA, this conference is vital for emergency department providers who might be new to the ED or need help in certain areas. The demand for this conference was high and feedback positive, so ACEP and SEMPA have decided to hold a second installment of Phase I in August. The conference has also been renamed Emergency Medicine Academy.
ACEP’s Leadership and Advocacy Conference will be May 18-21 in Washington, D.C. If you’ve never been to this conference, you’re missing one of the best three days of education and networking available. Thought-provoking, inspiring and challenging sessions by nationally recognized speakers and key decision makers will provide you the inside information and skills you need to maximize your impact as an emergency medicine leader and advocate. Invited Speakers for the Conference include: U.S. Sen. Ron Wyden (D-OR); U.S. Rep. Andy Barr (R-KY); Amy Walter, Political Analyst for the Cook Political Report; Patrick Conway, MD, Deputy Administrator for Innovation & Quality & CMS Chief Medical Officer. Please plan to come to Washington, D.C., next month to network with ACEP leaders and advocate for your specialty.
Please remember the elevator speech when you run into your hospital leaders and legislators:
We are 4% of the physician workforce seeing 28% of all acute care visits. We are the doctors of first contact, unscheduled, federally mandated care regardless of financial status. We are over 32,000 ACEP members seeing 130 million patient visits, 24/7/365 for about 4% of the national healthcare dollar. Our customers include primary care docs who send their patients to us for complex medical diagnostic work-ups. We are the portal of entry for 75% of all hospital admissions. We are the hub of the enterprise, and are working toward being masters of transitions of care. We are not only expected to be the admittors, but also the admitting avoidance service through our work in care coordination. And we do this in a room, in a hallway, in ‘copters and ambulances during disasters large and small every shift of every single day.
Thanks for the Past Six Months
I started my EM practice in the 1980s, and there are many reasons I value membership and the friends I’ve made over the years. I can pick up a phone and dial a colleague anywhere for advice. Like all families and all democratic groups filled with the riches of a knowledge-based constituency, we will have disagreements and some conflict. It’s all for a better result and a strong organization, as long as we stick together. The knowledge I’ve gained in reimbursement and coding and practice management has paid me back every dollar I ever contributed to ACEP, EMF and NEMPAC. The education I’ve received at conferences has made my practice better and improved the care of my patients. I was proud to join ACEP then, and I’m proud to be its President today. ACEP is growing. ACEP is dynamic. ACEP gives you a good return on your dues investment dollars. Your partners, your colleagues are the members of the committees, task forces, sections, Board, Council, and technical expert panels that create our future. Let’s connect. See you at LAC and ACEP14.
Alexander M. Rosenau, DO, CPE, FACEP
President, American College of Emergency Physicians
Fellow ACEP Members,
For those who made the trip to Denver this past October, hopefully you were able to “add more science to your Scientific Assembly experience” by visiting the ACEP Research Forum. The forum included both oral and poster presentations highlighting cutting-edge research in our field. The Forum featured an expert panel discussing abstracts that have significant implications for emergency medicine practice or research. Last year marked the first for the ACEP Research Forum Scavenger Hunt. In order to bring additional interest, and add a little fun to the Research Forum, a scavenger hunt was created with collaboration from the researchers themselves.
The scavenger hunt consisted of a set of questions for each day of the forum for non-researchers reviewing the posters to complete. The answers could be found in the poster presentations and each question was followed by a clue to guide you along the way. Questions for the hunt were contributed by over forty of the presenting researchers. The contributors were enthusiastic about the scavenger hunt, stating “It’s a great idea!! Very excited about it.” Another researcher appreciated that “It helped me not wait until the last minute to do my poster.” Summing up the goal of the scavenger hunt well, another contributor commented, “Thanks for increasing the awareness of the research projects.
Those who completed the scavenger hunt were submitted into a drawing for prizes: Virtual ACEP membership and ACEP bookstore gift certificates. One participant who completed the Scavenger Hunt commented, “It forced you to get a look at the whole range of research EM physicians are involved in, instead of gravitating only to your area of interest.”
Cutting edge research is presented every year at the research forum by hard working practitioners in our field. Efforts to increase awareness and participation by non-researchers in the forum should be continued. The Scavenger Hunt is again being planned for the upcoming conference, ACEP13 in Seattle. Be on the lookout for a new and improved Scavenger Hunt with improved convenience and ease of access. Of course, don’t forget about the exciting ACEP prizes for those cunning enough to navigate the hunt!
Alicia Glynn, MD
Case Western Reserve University/Metro Health Medical Center/Cleveland Clinic
ACEP has arranged for its members to receive a 20% discount on the FH Fee Estimator, a new source of independent charge data from private insurance claims. Participants can access emergency medicine charge data for 491 geographic areas nationwide. This tool gives physicians and management a better understanding of the marketplace and allows instant compare charge data to Medicare fees.
The FH Fee Estimator website, www.feeestimator.org, is easy to use for small data requests. But if you need a more sophisticated data set, contact FAIR Health for custom analytics. To get the ACEP 20% discount, enter the promotion code 20ACEP13 at the checkout screen.
FH Fee Estimator is brought to you by the not-for-profit corporation FAIR Health, whose mission is to bring transparency to healthcare costs through comprehensive data products and consumer resources. Created in 2009 to provide an objective source of data, FAIR Health owns and maintains a database of billions of billed medical and dental services. This database serves as the foundation for benchmark products that reflect the prices charged for healthcare services in specific geographic markets across the country.
This database is a great resource for emergency physicians groups to inform development of fee schedules and other practice decision making, says David McKenzie, CAE, ACEP’s director of physician reimbursement. The data is available based on an aggregation of zip codes and can be tailored for the geographic area you serve. Because it is drawn from actual claims data, it is a wonderful source of information on fees charged in your area, he adds.
ACEP Calls for Increased Investment in Mental Health Resources and a Ban on the Sale of Assault Weapons
The American College of Emergency Physicians (ACEP) today expressed deepest sympathy to all those affected by the senseless tragedy in Connecticut and called on government at every level to increase investments in mental health resources and to ban the sale of assault weapons and high-capacity magazines.
Emergency physicians see the tragic consequences of gun violence every day. Our hearts go out to the families of the victims and to everyone affected by this terrible event in Newtown. We deplore the improper use of firearms and support legislative action to decrease the threat to public safety resulting from the widespread availability of assault weapons. We also are urging policymakers to restore dedicated funding for firearms injury prevention research.
ACEP’s policy on firearm injury prevention endorses limiting the availability of firearms to those “whose ability to responsibly handle a weapon is assured.” It also calls for aggressive action to enforce current laws against illegal possession, purchase, sale or use of firearms.
The nation’s emergency physicians call for increased funding for the development, evaluation and implementation of evidence-based programs and policies to reduce firearm related injury and death. We will fully support legislation that supports the principles of ACEP’s policy on firearms injury prevention.
The lack of mental health resources in the United States has contributed to a significant increase in visits to the emergency department. Psychiatric emergencies grew by 131 percent between 2000 and 2007, according to a recent study in Annals of Emergency Medicine. This is symptomatic of the lack of resources for these patients.
Although ACEP has previously reviewed the Choosing Wisely Campaign and agreed not to participate, due to continued questions and comments from our members, I convened a workgroup to re-review the campaign and ACEP’s participation. The workgroup consisted of a wide and diverse representation of ACEP members and Committees.
The group was overwhelming in support of not joining the Choosing Wisely Campaign. Although the issue of cost control is crucial for emergency medicine’s future, the Choosing Wisely Campaign is not the vehicle for ACEP’s participation.
Several important points were made during the workgroup meeting:
- The College needs to be viewed by CMS, payers, and the public as proactively addressing cost containment and overuse.
- ACEP needs to be seen as proactively providing solutions rather than appearing to be against any cost cutting or savings suggestions.
- The College developing and communicating a plan with proactive proposals/solutions will mitigate some cost cutting measures from those that do not understand the unique position of emergency care. It was noted part of the success of the Washington State initiative was the ability to come to the table with a plan, rather than push back against the plan of action presented by the State.
- Whatever is developed should showcase the specialty in a favorable light and not contradict or conflict with current advocacy efforts.
- There was support for identifying over-use and developing a positive message on cost savings and efficiencies in the emergency department.
- To come to consensus on a certain number of tests or services that have limited use would require so many caveats that it would be almost impossible to develop lists as found in the Choosing Wisely Campaign.
- Ideally any recommendations should include some liability reform/recommendations in using guidelines that may suggest certain tests or procedures are not effective or necessary.
It was recommended that ACEP develop a task force from committees, sections, and members with expertise in these areas to develop a proactive campaign that recognizes the role the emergency department and emergency physicians can play in controlling costs while improving efficiencies and quality patient care.
The process has already begun with the task force being constituted with the goal of developing messages and strategies for cost control in the emergency department. The task force will make their recommendations at the October ACEP Board of Directors meeting.
We also will be educating our members about cost savings programs from other specialties, such as the Image Wisely and Image Gently programs from the American College of Radiology.
DAVID SEABERG, MD, FACEP
President, American College of Emergency Physicians
A campaign called Choosing Wisely has gotten some attention of late because of its stated goal of reducing health care costs by eliminating tests and procedures that are not “necessary.” Since Choosing Wisely launched, nine medical specialty organizations have offered up their top five items for the chopping block. These range from CT scans for fainting from the American College of Physicians to antibiotics for chronic sinusitis from the American Academy of Allergy, Asthma and Immunology.
ACEP was asked to join the campaign in 2011, and after extensive review and discussion at the Committee level, ACEP declined. There are several reasons for our initial response:
- Emergency physicians have no right of refusal with our patients and often pick up the slack for other members of our esteemed profession. A recent member poll showed that 97% of us report seeing patients on a daily basis who are sent to the emergency department by their primary care physician. Many of these patients have been sent in with expressed instructions from the family physician to have this or that test ordered either because their office practice is swamped, the office is closed, or they lack the facilities to perform these tests.
- ABIM, the organization sponsoring the campaign, refused to allow any discussion of liability reform as a component of the Choosing Wisely campaign. To quote from the letter ACEP Past President Dr. Sandy Schneider sent to Daniel Wolfson, ABIM’s Executive VP and COO: “This is a significant issue in emergency medicine and a critical factor as to why emergency physicians order the number of tests and procedures they do. Unlike primary care physicians, emergency physicians are not chosen by their patients, who have a greater tendency to sue for any perceived untoward event. In addition, we often lack prior care information. It is simply not possible for emergency physicians to talk about reducing ‘unnecessary’ testing without including messages about the need for medical liability reform.”
- Emergency physicians approach our patients with the goal of eliminating anything life threatening. We cannot afford to miss anything, even something that seems like a long-shot. The consequences may be life or death for our patients. A test that is unnecessary for 99 patients may save the life of patient number 100.
- Emergency medical care constitutes just 2 percent of all health care spending in the United States, no doubt in part because so much of the care we deliver is uncompensated. We are masters of efficiency and improvisation but there is only so far a dollar can be stretched. Emergency departments have been closing at an alarming rate across the country because so much care isn’t paid for. This is not the place to cut costs any further.
- Lastly, should ACEP participate in this campaign, it very well may assure that emergency physicians will not receive reimbursement for the five identified procedures or tests.
ACEP is dedicated to advancing emergency care and promoting evidence-based quality improvement measures for its patients. To that end, we are reevaluating our response to the Choosing Wisely campaign by developing a workgroup, comprised of members from the Reimbursement, Medical-Legal, EM Practice, Clinical Policies, Quality and Performance, and Public Relations Committees to examine the issue and prepare a proposal for ACEP Board consideration.
DAVID SEABERG, MD, FACEP
President, American College of Emergency Physicians
Sandra Schneider, MD, FACEP, ACEP Past President
I would like to personally invite you to become a member of the Emergency Medicine Practice Research Network – EM-PRN. Becoming a member is simple; just click on this link and answer a brief survey. It will take less than five minutes. We want to know if you are seeing patients with chronic pain, we want to know if you are experiencing medication shortages and how you are coping. We want to know how you practice. YOUR ANSWERS will provide ACEP with essential information for our advocacy in Washington and improving emergency care. To stay a member, all you need TO DO is to agree that you will complete 3-4 surveys, five minutes or less, each year.
Membership at this time is only open to ACEP members, residents, attendings and life members. Sorry, we cannot as yet accommodate non-members or medical students. Many other specialities have built practice research networks. Pediatrics has had one for more than a decade. They started small, like us. They have found that getting data from physicians on the front lines is often very different than getting it from inner city, teaching hospitals. Once you join EM-PRN, you will be able to do much more than just give opinions to survey questions. We want to submit ideas for research projects and survey questions that YOU would be interested in. Our group will pick the more interesting and the most popular IDEAS for the next survey. So you not only will be providing answers, you’ll be designing the questions.
Right now and for the next few years, EM-PRN will be largely surveys. Eventually, we will likely want to grow to collect some data. For example, IN THE FUTURE we might want to monitor the number of patients seen with chronic pain in emergency departments. You would simply count the actual number of patients you see during a single shift (no names, no identifiers) and submit it to ACEP.
We could then monitor this number over time to see if it is increasing, decreasing or staying the same. The members of EM-PRN will help direct what research projects we consider and will be acknowledged on any publication. Members will also receive the results of any project ahead of publication. So in the time it has taken you to read this Blog, YOU could contribute to advancing our knowledge of the real practice of emergency medicine. Join now.
Did you hear? “The ER physicians and hospitals have been abusing their privileges as providers of ER services for years,” according to the Chief Medical Officer for the Washington State Medicaid Program.
These are the statements that make involvement in organized medicine and participation in leadership at all levels critical. But where do we acquire the skills to combat these misperceptions and outlandish statements?
In May every year, there is a one of a kind event in Washington, DC called the ACEP Leadership and Advocacy Conference. It is an intimate conference with about 500 attendees, representing leaders in emergency medicine from across the country.
The conference focuses on principles of leadership, current issues in advocacy, media training, and practical everyday leadership challenges that will confront leaders in every state. It is also an excellent opportunity to network with colleagues from across the country.
When I first attended 5 years ago, I went as a member of the EMRA Chair’s Challenge and the incoming Legislative Advisor for EMRA – a neophyte to organized medicine by all accounts. It was an eye-opening experience to be talking with the leaders of our specialty. These were the people and faces that went with the legendary names I read about in Annals and ACEP News. Now I was talking with them, learning from their experiences and stories, and finding out how varied the opportunities were in emergency medicine.
From chairs of departments, leaders of advocacy groups such as the AARP, AMA delegates, speakers of the council, and so many others, I had the chance to see and live the history of our specialty. Then on the final day of the conference, we put it all together and walked up to Capitol Hill as hundreds of physicians representing our millions of patients to share our stories with elected officials and change the face of medicine.
This year it is my privilege to share with you my experience in Washington State, having put these skills into action on the local level. When I joined the Washington ACEP Board of Directors, I never imagined I would use so much of what I learned at LAC. From media training skills in doing press interviews and the gotcha journalism warnings, to relationships I have leaned on for statistical assistance in fighting misleading information, and the practice of speaking with legislators – these are all invaluable skills.
If you have the slightest of desire to join the leadership of emergency medicine in your hospital as a facility medical director, at the state level in an ACEP Chapter, nationally on a committee, or be involved in one of the hundreds of other ways possible, I encourage you to attend ACEP’s Leadership and Advocacy Conference in May. It is the conference that I walk away from every year re-invigorated and ready to take on the challenges of caring for our patients in the halls of our department, but also and more challenging often, the halls of the Legislature. You will not regret coming to DC, but you might just regret missing it!
In all my career, I never met a patient that taught me so much as Staci. Staci, a 25-year-old business owner who presented with headache. A very routine case. You see, she has had similar headaches before. Strong family history of migraines. Her headaches usually get better with Excedrin but every once in a while comes to the ED for compazine or reglan with benadryl. This was no different this time. Normal exam, photophobia, no neck stiffness. She was treated in the usual fashion and felt much improved. She went home and smiled as she said thanks and good night. The next day Staci had more pain, worse than before. Imaging was done and the radiologist saw something suspicious. MRI showed a tumor. It had the classic appearance of the last thing you want to hear. After a workup, biopsy, and surgery she awoke on October 14, 2009 in the recovery room very cheerful and told everyone around her how much she appreciated the care she received. In the days that followed she was aware of her diagnosis of brain cancer. The neurosurgeons got all of it but wanted her to have chemotherapy, just to make sure.
At St. Joseph’s there was concern about long lengths of stay and tremendous cost of EOL care. The Dartmouth study came out showing NJ as the state with the highest cost for end of life care. I had continued my interest and was on EOL committees and involved with the local hospice. I had plans to take the palliative medicine boards being offered about one year later, in November 2010.
A month later Staci came in to the ED. She again had headaches. She was getting the chemotherapy. When I spoke to her the first thing she said was thanks for caring about me. Her neurosurgeon asked her to come back to the hospital and see what was going on. A CT showed post-op changes and mass effect. I felt comfortable telling her the tumor was back. I explained that the path report showed a highly aggressive tumor. I explained that some people don’t survive this. I asked her if she had been told this before. She said never. I was horrified. What have I done? She made me feel better when she then said that no one told her but she knew she got her medical record and knows she has a glioblastoma. She knew she would take a trip soon She didn’t know when See, Staci would say she was dying, she insisted she was taking a trip to Milan. She was waiting for her doctors to confirm it. They told her it doesn’t matter what it is – focus on the treatment.
Staci was scheduled for surgery just after Thanksgiving. She had been in the ED twice for pain. Every time we spoke she said thanks. She said she made goals to spend Christmas with her family. She knew she could do it.
Staci’s surgery went well medically but the tumor had grown much faster than they thought. She would not leave the hospital. She was going to be admitted to inpatient hospice. Well, that’s what the surgeons and oncologist said.
December 11th Staci painted her nails stiletto red and signed out of the hospital AMA.
Over the next 14 days she put her life in order. She sold her business and took care of all financial issues, made arrangements for her pets and had plans for her clothes and furnishings to be donated to a women’s shelter. She put her house on the market and decorated it for Christmas. She even bought Christmas presents. Wrote notes to her nieces and watch her favorite basketball team with her dad. Her health continued to decline but her pain and non-pain symptoms were well controlled. She told me she was going to make it to Christmas but not to New Year’s. On the 23rd she wrote the 22 things you must do before you die. Staci slept most of the 24th and couldn’t have Christmas Eve dinner with her family. She wasn’t upset about this. She couldn’t eat anyway. She was saving her energy for the 25th. Her nieces woke her at 5am. Late on the evening of the 25th she told me it was the best Christmas ever. Her mom and dad were there, her nieces and all those she cared about . She was ready for her trip, she said. I asked her when she was leaving. She said in a couple days. I last heard from her on the morning of Dec 28th. She said goodbye and thanks. She asked me to share her list of the 22 things to do before you die. She died in her sleep that night.
22 things to do before you die:
Tell people that you love that you love them.
Plan your flight (will, burial, monies, belongings…..) dot the “i’s” and cross the “T’s.”
Keep Pushing … what’s the worst that can happen?
Don’t worry about things you never had a chance to do. Cherish the things you did.
Find a way to laugh.
Give hope to those still in the fight.
Run up your credit cards, Banks are the last to know.
Acknowledge the people who are close to you will be sad and think it’s not fair;.comforting them for some reason comforts you.
Make peace with friend and foe.
Cover your mirrors … don’t dwell on how you look now. What you see in the mirror is cancer, that’s not you
It’s OK to cry even if you tell others not to.
Take care of your pets. They love you unconditionally. Leave plenty of food and water out for them because friends and family will forget to feed them.
If there are children or loved ones write a letter in words they can understand.
Record an audio message; videos show death but your voice doesn’t have to reflect that.
Keep in mind that no parent nor spouse wants to watch you die; comfort them. Let them know it’s not their fault. They will never forget that conversation.
Live your life and live your death like a Dr Seuss book, “I will never say, I wish I would have could have!”
Keep pushing; drink Red Bull. You have plenty of time to sleep when you are dead.
Support groups are fine – BUT – having one true friend listening is like Mastercard commercials: Priceless.
Die at home if possible. Sign out of the hospital. Don’t turn your home into a morgue; have as little medical equipment as possible.
Believe in things that are out of sight – Santa Claus, flying reindeer, virgins have babies, and me!
Don’t let a scared family member call 911.
Know when to give up your car keys.
On Jan 7th St. Joseph’s started an ED-based palliative medicine program and Palliative Care Emergency Center. We have treated and cared for more than 300 EOL patients in the first 18 months.
Thank you, Staci.
Mark S Rosenberg, DO, MBA, FACEP, FACOEP-D
Chairman, Department of Emergency Medicine
Geriatric Emergency Medicine and Palliative Medicine
St. Joseph’s Healthcare System
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