Archive for category Uncategorized
Why bother blogging…it’s all about Advocacy (maybe)…
Posted by bfeligi in TheCentralLine.org, Uncategorized on August 1st, 2010
Let’s face it. I’m an old dude. I have only been practicing emergency medicine for 16 years but I have 5 years of post graduate training and went to medical school late in life. Sooo…when it comes to this” techie” stuff I am in my infancy. My 12 year-old and certainly 20-year old have me beat. However, as painful as this may be, I decided to “step-up to bat” when I received a note from ACEP asking if I might be interested in blogging.
Don’t get me wrong, I have a few computers and they are not like my first, a Tandy, from Radio Shack that cost me more than three computers in today’s world and it worked on “floppy disks, but now I am really dating myself. Look, everyone needs to try new technology. I remember my first hand held calculator that I received for college – it weighed about one pound, cost about $100 and could add, subtract, and do square roots!
Now I even have a Blackberry so perhaps I’m not that much of a novice with technical gadgets but I refuse to switch my carrier to AT&T for an i-Phone (although it does look like fun). And, I even have Twitter, but use it anonymously, since I really don’t think people who don’t know me are that interested in what I’m doing every minute of my life.
As a faculty member in an emergency medicine residency, I was convinced to actually join Facebook. Perhaps, it was done out of pseudo-peer pressure, but it has added to the camaraderie in the Emergency Department and has reduced stress levels amongst the staff.
Well enough said about the technical aspects of blogging other than the time commitment to blog. As a start, I will try and commit to a weekly entry since I have to still work my shifts, teach, take care of administrative issues, and of course be a “real person” outside the ED. It does scare me looking at all the gizmo’s on this website that the reader doesn’t see like icons for You Tube, insert points for cameras, video, google, Spike….Perhaps I’m out of my league but time will tell!
Oh yeah…one more thing…why was I asked to blog anyway? Since I have been involved in federal and state governmental affairs with both ACEP and my state chapter, it was suggested that physicians may want to hear a member’s perspective on advocacy. I will be the first to acknowledge that I am no expert; there are far smarter people out there than me, but hopefully my opinions and observations may motivate others to become more involved in this process.
For now, please forgive me as I get oriented to the site and all the bells and whistles on this side of the keyboard…and thank God for spellchecker…Wow and I kept it under 500 words…awesome.
What Is An Emergency Physician?
Posted by Marlene Buckler, MD, FACEP in Uncategorized on July 5th, 2010
What is an Emergency Physician?
There’s an old riddle. How many legs does a dog have if you call the tail a leg? The answer, of course, is four, because calling the tail a leg does not make it a leg.
Calling doctors who practice full-time emergency medicine something other than emergency physicians does not make them something other than emergency physicians.
Any doctor whose main job is to work full-time shifts in a hospital emergency department is, by definition, an emergency physician.
How in the world did we ever forget this simple fact?
Recently some have tried to characterize a portion of the EM workforce as being “family physicians who work in emergency medicine” and other similarly euphemistic titles.
Look, it’s really simple. We don’t need euphemisms adding confusion to an already tenuous medical system.
I am an emergency physician.
My sole medical practice is working full-time in hospital emergency departments.
I see the same patients that are seen by EMRT and/or ABEM-boarded docs.
I assume the same liability as that assumed by EMRT and/or ABEM-boarded docs.
I am held to the very same standards of care.
So, can we just forget all of this foolishness and get on with our work?
The discrimination against non-boarded and non-EMRT emergency physicians, both by hospitals and by ACEP is not only insulting, it is counterproductive.
Let’s give it a rest so we can all work together. We all have better things to do with our time and we owe much more to the patients who come to our ER’s.
Marlene
Marlene Buckler, MD, FACEP
www.StayOutOfMyER.com
Concerns of an ACEP member
Posted by Marlene Buckler, MD, FACEP in Uncategorized on July 1st, 2010
Many concerns of non-ABEM-boarded ACEP members have been circulating recently on the Certification and Workforce section elist.
As a long-standing member of ACEP, and speaking as an individual, I would like to share a few thoughts.
A few years ago, when I moved from Plant City to Sarasota, Florida, after leaving my marriage, I was forced to continue working in Zephyrhills (an 85-mile one-way drive) because all six hospitals within a 20-mile radius of my Sarasota home refused to even consider me for work in their ER’s, because I was not board certified. All of these hospitals, by the way, used mid-levels in their ER’s.
As soon as the question of board certification is asked and answered the discrimination begins. I think some of you remember the struggles I have had in Florida with hospitals that refused to allow non-boarded docs on their medical staff.
If ACEP truly represents all of its members, and if it is able to recognize the realities of the workforce situation in America, it should do the following:
- Welcome all full-time emergency physicians, i.e. those who work in the trenches on a daily basis, into ACEP as active members.
- Work to minimize or eliminate the obvious class system that exists in the College and in the workplace.
- Be true advocates for all of its members, not merely those who are boarded.
- Remember that it is a professional association, not a certifying body, and act accordingly.
- Encourage individual hospitals to judge each EM physician who wishes to apply for an advertised position, on his or her merits.
- Put the interests of its medical members above the interests of mid-level practitioners.
It is not enough for ACEP to point to its Policy on Legacy Physicians and to claim that the College cannot and should not interfere with decisions of hospitals. The reality is that many ACEP members sit on the credentialing committees where they work ,and therefor can influence hospital policies and by-laws. As individuals (not necessarily as ACEP representatives) these doctors can advocate for their non-boarded colleagues.
Any ACEP member who claims to be supportive of Legacy Physicians, and who does not attempt to influence his or her individual hospital’s policy in this manner, is not sincere.
Actions speak louder than words.
It is my opinion that ACEP should re-open active membership to all full-time ER docs who wish to pay the high yearly fees.
ACEP must stop behaving in a way (either by commission or omission) that undermines the efforts of non-boarded members to find and keep jobs and to become qualified by routes other than the closed ABEM practice track to certification.
In a democratic association elitist behaviours have no place, and should not be tolerated.
Respectfully, Marlene
Marlene Buckler, MD, FACEP
A Doctor’s Guide To Avoiding The Emergency Room
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ACEP Section E-list: cert.section@elist.acep.org
The Show
Posted by VeronicaB in Uncategorized on June 24th, 2010
I don’t know that I’ve ever stopped to think about what patients see while waiting in the emergency department. I thought about it today when first we brought a code into our Room One, and then later at the end of the shift I sutured the back of someone’s ear back together in the same room.
There’s a hallway bed that sits just outside of Room One. It’s our Front Row Seat. It’s the spot between the front doors and the code room – Room One. It’s the chair/gurney where the grannies sit waiting for their AMS work-up. It’s the spot where the intoxicated either snore loudly or fight loudly while they wait for a secure room. It’s the spot to be to see everything that’s going on in the E.D. You see what comes in. You see what goes out.
Today while I stood waiting in Room One I saw concerned family members standing next to their loved one watch as paramedics rushed a semi-naked intubated patient into the code room while an EMT pushed one-handed on the patient’s chest. As the door slowly closed shut, I caught glimpses of faces: curiosity, concern, fear. They watched as I exited 20 minutes or so later, my face grim with thoughts of what I had to do next: call family, call the ME, catch up on the patients that had waited while I ran the unsuccessful code. I know they looked from me to the door, knowing that whatever had happened to the patient behind it had not gone well.
Later, while I was suturing a patient in that same room, a Granny was sitting in a wheelchair facing the room. She followed me with her eyes as I grabbed the suture cart and dragged it into the room. She watched with interest as I set up my table and loaded the syringe. She tilted her head once or twice while I sewed the laceration which was faced away from her. She watched me wheel the patient back into his hallway spot, and I could tell she tried to sneak a peek; however the bandage was in the way.
I wonder what she thought sitting in her chair watching me suture. At least I provided a small diversion while she waited… and waited… and waited….
Meisel & Pines Slate article on the importance of speedy ambulance transport to the ED
Posted by jpines in Uncategorized on May 12th, 2010
Zachary F. Meisel and I just yesterday posted an article on Slate about the public health impact of speeding ambulances, focusing on the issue of lights & sirens. While I try to be a fierce advocate of emergency care and emergency personnel in general, I got the idea for this article after an ambulance, riding “hot”, nearly ran my family and me off the road.
This episode got me thinking, does it make sense from a public health standpoint for ambulances to put citizens at risk to get patients to the hospital faster? We highlighted a recent paper published in the March 2010 issue of Annals of Emergency Medicine which elegantly investigates the issue of “the golden hour” in trauma patients using sophisticated statistical methods.
Newgard CD, Schmicker RH, Hedges JR, et al. Emergency medical services intervals and survival in trauma: assessment of the “golden hour” in a North American prospective cohort. Ann Emerg Med. 2010 Mar;55(3):235-246.
http://www.ncbi.nlm.nih.gov/pubmed/19783323
Check out our article on Slate.com:
http://www.slate.com/?id=2253638
-Jesse M. Pines, MD, MBA
March-April Annals podcast
Posted by David H. Newman, MD in Annals of Emergency Medicine, Uncategorized on May 11th, 2010
FINALLY! Sorry folks, we’ve had a minor technical glitch, we’re working it out and will be on time and rolling soon, with a higher quality sound and some VERY cool features. For the meantime, here’s the hybrid March/April podcast breakdown:
Pulmonary Embolism – Three MAJOR articles on PE, including testing for and diagnosing the disease
Safety risks in the ED – EP perceptions, compared to national safety goals
Inadvertent epinephrine overdoses: how to avoid this common problem
Cyanide poisoning: two randomized animal trials and an interview with toxicologist Richard Dart
Check it out, and stay tuned!
- David and Teri
The Balance Billing / Fair Payment / Hospital-based Physician Conundrum
Posted by Myles Riner, MD in Managed Care Contracting and Payment, Uncategorized on May 5th, 2010
Efforts to prohibit balance billing by non-contracted hospital based physicians, especially for emergency care patients, continue to confront ACEP state chapters left and right (or should I say North, South, East and West). It is pretty clear that many legislators and insurance regulators see this as a consumer protection issue, predicated on the fact that in an emergency, most patients do not have the ability to shop for providers that are contracted with their health plan; and that when they go to their ‘networked hospital’, it is with the expectation (often built upon misleading health plan assertions) that all of the docs at this hospital will be contracted with their plan. Health plans, regulators, and legislators are also motivated by the desire to contain costs; and for the plans in particular, prohibiting balance billing by hospital-based docs is the camel’s nose under the tent for control of all physician-related outlays.
The simplest solutions equate to fee setting. Fortunately, no one seems quite willing to go there….yet. I think this is because most folks recognize that setting fees at the wrong level could lead to disastrous unintended consequences, especially given physician shortages in this country. The AMA considers the balance billing issue to be a problem with ‘inadequate networks’, but pressure on plans to include more hospital based docs in plan networks often just results in more coercive contracting. This is where the plan pressures the hospital to leverage the staffing contracts of the hospital-based docs, to force these docs to accept deeply discounted contract rates with the plans. This has unintended consequences, too. Hospital employment of physicians would certainly ensure that these docs were contracted with all of the hospital’s networked plans; but hospitals are notoriously poor at collecting for physician services, and the downsides of the corporate practice of medicine are real. You would think the marketplace would have resolved this issue; but because of EMTALA and coercive contracting and the burden of the uninsured and the lack of good regulatory oversight; the market for emergency care services is really not a fair and free market.
The conundrum is: how do we make sure that emergency care providers and hospital-based physicians subject to EMTALA’s mandate are sufficiently compensated for commercially insured services so that they can meet their mission to provide care to all those uninsured and under-insured patients, and at the same time keep insured patients out of the middle of disputes between plans and providers over the reasonable value of emergency care and hospital-based physician services? One could argue that the patients should not be excluded from the debate, but the plans and legislators easily trump that argument with tales of egregious charges by a few ‘greedy doctors’. Hospitals and plans could be required to include physicians in three-way network contract negotiations, but that is impractical. Hospitals could be forced to provide subsidies to make up for the losses incurred by hospital-based docs who are forced to sign contracts with plans at deeply discounted rates; but many hospitals are already going bankrupt supporting flagging ER on-call rosters, and really it is the plans who are making most of the profits nowadays. Plans should not be able to say: ‘the uninsured are not our problem’. Some legislators (most recently in Illinois, in exchange for honoring assignment of benefits) have proposed fee arbitration as a solution, but the arbitration of millions of underpaid non-par claims is just ridiculous, not to mention hugely expensive. Any so-called solution that does not result in the vast majority of claims being paid appropriately up-front is doomed to failure. Others have proposed all sorts of inventive solutions to balance billing that would precipitate one or more serious unintended consequences by failing to address charge outliers or relying on fee setting or ignoring claims dispute resolution or relying on impossible claims management procedures. What is a well-meaning regulator or legislator to do?
One alternative is to try to get at the issue by addressing fair contracting rates for hospital-based physicians. Some advocates of what would essentially be ‘forced health plan contracting’ for hospital-based physicians argue that these physicians should accept contracting discounts from their usual and customary charges because their hospital’s networked relationships provide them with patient referrals, and that the only real question is: what is a reasonable contract rate? There are lots of different considerations that are usually exchanged for a fee discount in managed care contracting, referrals being but one of them. Determining a ‘reasonable contract rate’ is no easy matter, especially since contracting rates are supposed to be confidential between plan and provider, so getting at valid ‘usual and customary contracting rates’ would be difficult, if not an outright anti-trust violation. There are so many other terms and conditions negotiated in contracts with plans that establishing fair-market-driven contract rate standards for hospital-based physicians is probably a hopeless cause.
ACEP has addressed the balance billing / fair payment issue by developing a set of fair payment principles and model legislation. The ‘solution’ eliminates the need for balance billing and is predicated on using usual and customary charges to get close to the reasonable market value of non-contracted services and to address charge outliers, and on the establishment of a fair, fast, and cost-effective claims dispute mechanism to address the other causes of claims underpayment for non-contracted (and contracted) services. These and related documents can be found on the ACEP website: http://www.acep.org/advocacy.aspx?id=22188 This is a complicated issue requiring carefully constructed components and backstop measures to ensure a balanced approach to balance billing and fair payment.
Considering the fragile state of the emergency care system in the U.S., and the proclivity of legislators and regulators to ‘fix’ complex problems without really understanding them first; there are no perfect or easy solutions to the balance billing / fair payment issue that can be enacted without the risk of punching great big holes in the safety net, and making it impossible for emergency care providers to fulfill their mission. ACEP’s solution is neither perfect nor easy, and not everyone will be happy with it, but it is workable, and reasonable.
FEMA’s New Mobile Website
Posted by Harvey Castro, MD in Uncategorized on April 29th, 2010
The mobile Web site makes it easier to access critical information regarding emergency preparedness and what to do before and after a disaster right on a smartphone.
ACEP Measures the Emperor’s Nose
Posted by Liam Yore, MD in Uncategorized on April 22nd, 2010
A long time ago, in a faraway and mythical country which we’ll call China, everyone wanted to know how long the Emperor’s nose was. Of course to look at the Emperor’s visage was punishable by death. But so many people were curious, that a group of sages got together to look for a method of finding the answer, and this is what they came up with.
Questionnaires were printed and sent out in bundles to cooperating village chiefs, who distributed them to the peasants. Literacy was at a sufficient level that most were able to complete the single question, which was, of course: “How long do you think the Emperor’s nose is?”
When the forms were collected, mathematicians added up all the values, and divided by the number of forms. Thus it was known that the length of the Emperor’s nose was 6.734602 cm.
Read the rest of the post at Movin’ Meat
Stay Hungry
Posted by VeronicaB in Uncategorized on April 21st, 2010
Box Lunch ala Hospital
I don’t know that I’ve counted how many times during a shift I reach into the small fridge in the E.D. and pull out a box lunch for a patient.
Now, I don’t mind offering and giving a lunch to the LOLNAD* from the NH who’s been sitting in the ED for the last 6 hours after we fixed her skin tear while she continues to wait for the MediVan to come pick her back up. I also give box lunches to the EtOH MTF (metabolize to freedom) “private patients” aka regulars as my final sobriety test before sending them on their way.
The ones I am not quite sure about are:
– the 30-somethings who come in writhing on the gurney, dry heaving every time someone walks past the room, who complain of nausea, vomiting and diarrhea for the last 4 days to the extent they couldn’t keep down “even water” who, after having been given their Dilaudid, Zofran, and as the first drops of the liter of NS start to flow immediately sit up, start texting their friends and demanding something to eat
– the 80-something from the NH brought in for dehydration and altered mental status who can’t give you a history and barely follows commands during your exam whose daughter complains that “Dad hasn’t been eating well for the last several days and needs something to eat” because “we’ve been waiting here for such a long time” even though Dad came in via ambulance and she just showed up 17 minutes ago
– the 50-something diabetic sent in from their clinic with a glucose reading of “HIGH” who, even though it’s 1 p.m. and their clinic appointment was at 1100, states they “haven’t eaten since yesterday lunch” because they were too busy doing something with their church group
– any trauma… well, pretty much anyone who complains that they haven’t eaten in the last 12 hours who now needs surgery.
*LOLNAD from the “House of God” = little old lady in no apparent distress
