gregory m. christiansen, d.o., m.ed., facoep doctor, do ... · icd 10 coding systems, drug...

The PULSE APRIL 2012 1

a moment to reflect on this question? I am sure you can be creative to think of even the simplest ways to support your College. Remember way back when you were a student or resident. Would it not have been more helpful to have someone who has ‘been there’ to help guide you through your questions? Alternatively, have you ever asked a friend review your performance and ask, ‘how can I do better?’ Patient satisfaction surveys can’t offer that kind of direct and supportive feedback. A mentor can. I believe there is something you can do for ACOEP and indirectly also help yourself. You can join the ACOEP Mentor Program, and help guide and support those who follow a similar trail. They would benefit from your wisdom. When you engage and use your talents, you create opportunity for meaningful change. This promotes members who can then better navigate the development of their own trail. Simply put, you are important to the success of your fellow members. We would like the ACOEP to be the vehicle for your efforts.

We are facing an unprecedented array of challenges with multiple external entities attempting to diminish or restrict our ability to meet our mission. The future is uncertain and unpredictable. It has been said that nothing creates opportunity better than a crisis. Crisis creates controversy leading to struggle and conflict in search for solutions. Just open any newspaper and you can find a crisis in our field.

The irony of our situation is our relatively small size can often aid us in making a big

continued on page 4

Presidential ViewpointsGregory M. Christiansen, D.O., M.Ed., FACOEP

impact. The college’s nimble size gives us the opportunity to be at the forefront when issues demand our attention. Remarkably, we are growing more robust every year. We have marshaled resources to improve our communication and networking capabilities. We now have the ability to quickly reach our membership through our committee systems to address concerns. Addressing those concerns takes personal commitment and determination and it absolutely takes a focused membership to be successful. Some of the issues before us are challenging our organization for even more solutions.

On a national level we are struggling with a collective health system that ironically can’t afford to collectively care for those it mandates coverage. How are we to position ourselves in the face of the Affordable Care Act? Fortunately, we have an excellent support system in the AOA who informed the Patient Advocacy and Professional Affairs (PAPA) committee about the opportunity to engage in the conversation. Some members stepped up and made the effort but we need more members to participate. It’s our future at stake.

The AOA held a town hall meeting featuring fellow college member, the Honorable Congressman Joe Heck. He addressed our concerns on many issues including the SGR fix, EHR regulations, ICD 10 coding systems, drug shortages and residency training caps. He also addressed the Department of Defense recent attempt to limit our practice opportunities. To

APRIL 2012VOLUME XXXVIII NO. 5

It is an incredible experience to be associated with so many great people who make up our profession. ACOEP is an extraordinary organization with very talented people who get it. They are willing to get involved and selflessly perform exceptionally well. I had the chance to work with some of these folks as they attempted to identify and meet the challenges we face as an organization. These volunteers are willing to step up to lead our lot in these dynamic times. They lead out of necessity. They have been called to action because they have the vision of what needs to be done. The vision of our plan is not unlike a menu that presents a myriad of issues. We have pared down the variety to create a priority list which has become our agenda. The strategic plan is the result of a conference designed to set the priorities for progress for the coming years. The strategic plan outlines our mission statement and action plans for success, and will be available for you review on the ACOEP website.

So how can we - the members of ACOEP - meet the challenges before us? Do you have

Doctor, Do You Have a Moment?

The PULSE APRIL 20122

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The Pulse Editorial Staff:Drew A. Koch, DO, FACOEP-D, EditorWayne Jones, DO, FACOEP, Assist. EditorGregory M. Christiansen, DO, M.Ed., FACOEPMark A. Mitchell, DO, FACOEPErin Sernoffsky, Communication ManagerJanice Wachtler, Executive Director

Editorial Committee:Drew A. Koch, DO, FACOEP-D, ChairWayne Jones, DO, FACOEP, Vice ChairJulia Alpin, DODavid Bohorquez, DO Gregory M. Christiansen, DO, M.Ed., FACOEPJoseph Dougherty, DO, FACOEPAnthony Jennings, DO, FACOEPWilliam Kokx, DO, FACOEPAnnette Mann, DO, FACOEPMark A. Mitchell, DO, FACOEPErin SernoffskyBrian ThommenJanice Wachtler, CBA

The PULSE is a copyrighted quarterly publication distributed at no cost by the ACOEP to its Members, library of Colleges of Osteopathic Medicine, sponsors, exhibi-tors and liaison associations recognized by the national offices of the ACOEP.

The PULSE and ACOEP accepts no respon-sibility for the statements made by authors, contributors and/ or advertisers in this pub-lication; nor do they accept responsibil-ity for consequences or response to an advertisement. All articles and artwork remain the property of the PULSE and will not be returned.

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Deadlines for the submission of articles and advertisements are the first day of the month preceding the date of publication, i.e., December 1; March 1, June 1, and September 1. The ACOEP and the Editorial Board of the PULSE reserve the right to decline advertising and articles for any issue.

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Table of ContentsPresidential Viewpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Gregory M. Christiansen, D.O., M.Ed., FACOEPExecutive Director's Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Janice Wachtler, BA, CBA ACOEP Residency Spotlight. . . . . . . . . . . . . . . . . . . . . . . . . . . .6Diploma in Mountain Medicine . . . . . . . . . . . . . . . . . . . . . . . . .8J. David Keitz, D.O., FAWM, DiMMTricks of the Trade: Wound Irrigation . . . . . . . . . . . . . . . . . . . .9 P. Marvin Pustinger, D.O.In My Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Wayne T. Jones, D.O., FACOEPAOBEM Announcement about CAQs . . . . . . . . . . . . . . . . . . .10Life Happens. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Carly Snyder, D.O.Nova Southeastern Welcomes ACOEP Presidents . . . . . . . . . . .11Ashley Guthrie, OMS IIFOEM: Why I took the Pledge Plunge. . . . . . . . . . . . . . . . . . .12 Stephanie WhitmerAttempting to Decrease Head CT Utilization . . . . . . . . . . . . . .14 Jeremy D. Tucker, D.O. ACGME Impact Statements . . . . . . . . . . . . . . . . . . . . . . . . . . .15 John C. Prestosh, D.O., FACOEPOsteopathic Continuous Certification . . . . . . . . . . . . . . . . . . .16Mark Stone D.O. Looking Ahead to Scientific Assembly . . . . . . . . . . . . . . . . . . .18 Erin SernoffskyEditor Responds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Drew A. Koch, D.O., FACOEP-DWhat Would You Do?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Bernard Heilicser, D.O., MS, FACEP, FACOEP

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ensure our success the PAPA committee needs more members to get involved with their talents. For example we have the opportunity to participate in DO Day where we can directly develop relationships with our elected officials. It’s simple but has a huge impact. It is rewarding to have a connection with elected leaders who are willing to consider our issues. It opens doors for more opportunity.

For an excellent example of the impact our members are making, just look to our EMS committee. This committee is participating in the coalition to confront the DEA over its proposed regulations which seek to impose penalties on operational medical directors. The EMS committee is also expanding ACOEP’s presence internationally through sponsored activities and publications in WADEM. Our GME committee is addressing the epic battle with the ACGME whose proposals threaten training system and practice rights. As an organization we have proudly held ourselves as a model for quality

resident training to various regulatory bodies. Our steadfast commitment to quality has engendered support from other organizations like ACEP, AAEM, and CORD who have reinforced our training in direct response to the ACGME proposals. We are grateful for the support from these and other organizations. I recognize this is a direct result from the reputation ACOEP has built from the dedicated individuals who make up the College. It cannot be understated that the back bone to our success is the result of our members’ collective commitment to quality to patient care.

We are tackling these issues and moving forward to grow the college. We are blessed to have talented leaders in our College. By the very nature of our practice we have innate leadership skills; as emergency physicians we practice this leadership on a daily bases. We do it because our patients have asked us for our help. They depend on us to be there 24/7. It is who we are and it is my pleasure to humbly be a part of such a talented group. It is time for our members to bring their leadership skills

to the forefront. Their mentorship and networking will guide our College through even the most difficult challenges.

Engaging in mentorship offers the opportunity to use the human capital to its fullest potential. It can help catapult our college over issues and galvanize our standing as leaders. It taps the collective strength of the College to offer networking but goes beyond just making connections. It bridges our differences and offers perspective, leadership and direction. It offers professional development and cultural perspective. Experienced members can guide junior attendings on career development or research ideas, or even personal development. Junior attendings in turn can offer support to transitioning residents. Likewise residents can offer support and guidance to student members. Mentorship is a very powerful tool to meet our ultimate goal to better serve our patience. Together we can make our world better. Be a leader. Take the time to sign up on the ACOEP web site to be a mentor to someone who could use your talents. I thank you for your leadership!

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Sometimes I think that people think advocacy is a dirty word. People often equate advocacy with political lobbying or lobbying done by politically oriented people getting paid money to support

a cause. Sometimes the term itself drives people away from an idea or action and not to the cause; but in reality advocacy means several things. It means to support or back an idea; sponsor, promote or back a cause; it can encourage people to become involved or may be interpreted as activism on an organized or grassroots efforts. So when you ask, ‘are you an advocate?’ most of us would say yes.

As people, we advocate (or support) many causes, some political, some personal, some philanthropic in nature. As a physician you advocate for healthcare, available pharmaceuticals for treatment and the rights of your patients to ensure that they receive quality and adequate medical treatment in the healthcare system. You may advocate for your child’s soccer team. During your lifetime you may advocate for the rights of your family as they move through life, to support their need to have equal opportunities in schools and life. So it worries me why the ACOEP members don’t participate more when it comes to supporting the needs of their patients, emergency physicians and healthcare in general.

To advocate for your profession isn’t always easy, and many of us feel unprepared when it comes to speaking to a governmental official or staff member. But you can always speak of your personal experience and appeal to their humanity through your story. What about the time you were unable to appropriately treat a patient because your institution could no longer

Executive Director's DeskJanice Wachtler, BA, CBA

What is Advocacy and Why is it Important?

obtain a drug because the manufacturer no longer made it when it became unprofitable? Or the time your institution prevented you from giving a test to a non-insured or under-insured patient because it cost too much and the hospital wouldn’t receive reimbursement? What about your rural institution not being able to recruit adequate physicians to take care of its patient base because it had exceeded its cap and you could not establish the program? These are all issues that you can easily speak to when you meet these political figures or staff.

To advocate isn’t always convenient; sometimes you have to write letters at night or on weekends, you may have to visit your congressmen and senators when they are at home in their district on your day off; and yes, we all want to do something fun or relax on days off, but sometimes you can’t. Sometimes it may mean that you have to travel to Washington DC and spend more money on hotels and transportation to conduct this advocacy and show your support for a cause. Is it neat and tidy? No. Convenient? Not so much. Is it challenging? You betcha.

Am I an advocate? Yes, I am. I advocate for many things. I advocated for the rights of veterans after the Viet Nam War; I have advocated for the rights of my parents (and other senior citizens) who stood the chance of losing benefits. I have advocated for philanthropic support of our own Foundation, the National Wildlife Society, and several different campaigns to protect wildlife or cats and dogs. I have advocated for political candidates that I truly believed would make a difference; sometimes they held to the things they supported, other times not. But throughout each effort, I personally got some satisfaction. Sometimes I took pride in my participation and support other times I cringed because it blew up in my face. But when all was said and done, I feel that I made a difference.The enemy of any advocacy effort

is apathy; an indifference to a cause or perhaps lethargy of a membership. We have routinely called upon our members to make a difference; to advocate for healthcare reform; support your rights as an emergency physician. At times we have provided energetic support to these causes, but lately the turnout has been lackluster.

In today’s healthcare environment, with threats to your patients, your practice, and your paycheck, this is not the time to be lethargic; it is a time to challenge your legislators (at home or in DC) and make them hear your voice. We can meet this as a chorus of many voices supporting a single message; many voices calling forth to Washington DC, your local district or your own state capital. A voice that will not be quieted until the issue has been solved, not to the satisfaction of the insurance groups, but to you the medical practitioner. Now is the time to get off your chairs, out of the offices and emergency departments and take to the airwaves and sidewalks and offices of your legislators to make them hear your single voice singing a song of strength and certainty and supporting the rights of patients and physicians nationwide. And you will make your message heard, that we will no longer practice medicine that is not of a quality to adequately treat patients in emergency settings or practice in an environment that restricts your access to providing care.

ACOEP cannot do it alone, we need your help. We need to have you to contact your legislators at home; walk the Halls of Congress at events like DO Day on the Hill. We need you to provide a voice for emergency medicine in your state associations and on the floor of the House of Delegates and AOA committees; we need you to work on our committees and provide grassroots support, and in general, we need you to be involved.


CCOM Emergency Medicine]St.James/Midwestern University 20201 S. Crawford AveOlympia Fields, IL 60461

Hospital Information:Type: Community Trauma Level: ComprehensiveNumber of Hospital Beds: 164Number of ED Beds: 25

EM Program Information: Phone: 708-747-4000 ext 1335Website: www.midwestern.edu Total Number of EM Residents: 67 (3 clusters within one program, with 1-3 affiliate sites for a total of 9 sites). Residents to Attending Ratio Working Clinically: 1:1-3Accepts Medical Student Rotations? Yes, contact program for further details.

EM Program Curriculum: PGY 1: Pediatrics, OB/GYN, Surgery, Elective, Vacation, Internal Medicine, EMPGY 2: Trauma, PICU, Radiology, Vacation, EMPGY 3: Trauma, Ortho, CCU, Vacation, EMPGY 4: EMS, Research/Admin, Toxicology, EM

EM Program Application Information: Dates applications are accepted: August Prefers COMLEX Scores >500Interview Dates: September-December Letters of Recommendations: 3; EM Preferred

Kingman Regional Medical Center3269 Stockton Hill RoadKingman, AZ 86409

Hospital Information:Type: RuralTrauma Level: IVNumber of Hospital Beds: 235Number of ED Beds: 30

EM Program Information: Phone: 928-757-0649Website: azkrmc.com; weloveouthospital.com; kingmanemergencymedicine.com Total Number of EM Residents: 16 Residents to Attending Ratio Working Clinically: Accepts Medical Student Rotations? Yes, contact program for further details or [email protected]

EM Program Curriculum: PGY 1: EM, General Internal Medicine, Specialty Internal Medicine, General Surgery, Surgery Specialty (Urology), OB/GYN, Pediatric EM PGY 2: EM, Intensive Care Unit, Ortho, Anesthesia, EM Services, Neurology, Pediatric Intensive Care, Elective PGY 3: EM, EM/Admin, EM/Research, Radiology, Trauma Critical Care, Trauma EM, Pediatric EM, Elective PGY 4: EM, Toxicology, Elective

EM Program Application Information: Dates applications are accepted: November 1st Prefers COMLEX Scores Interview Dates: October 1st Letters of Recommendations: 3

ACOEP Residency Spotlight

Arrowhead Regional Medical Center400 N. Pepper Ave., MOB, Suite #107Colton, CA 92324

Hospital Information: Type: CountyTrauma Level: IINumber of Hospital Beds: 456Number of ED Beds: 48

EM Program Information: Phone: 909-580-1862Website: www.armcemergency.org Total Number of EM Residents: 28Residents to Attending Ratio Working Clinically: 2:1Accepts Medical Student Rotations? Yes, contact program for further details.

EM Program Curriculum: PGY 1: EM, Anesthesia, Medicine, Peds, MICU, OB, Surgery, USPGY 2: EM, Ortho, SICU/Trauma, MICU, EMS PGY 3: EM, Research/Admin, EMS, EM Pediatrics PGY 4: EM, Elective, Surgical Subspecialty

EM Program Application Information: Dates applications are accepted: July 1-November 1Prefers COMLEX Scores: >450 if rotate in the ED, >500 if did NOT rotate in the EDInterview Dates: September-December Letters of Recommendations: 3 by EM Physicians

At ACOEP, we are proud to be affiliated with each of our emergency medicine residency programs. These institutions produce outstanding physicians that strengthen the osteopathic community and provide excellent care to their patients.

Moving forward we would like to shine a spotlight on each of these programs in turn, providing a resource to our students as they find their matches and other members keeping abreast of the trends in osteopathic training. With incredible work from Resident Chapter Vice President, Megan McGrew, this information at-a-glance provides a starting point for students as they become better informed about what each program offers.


St. Lucie Medical CenterPalm Beach Centre for Graduate Medical Education1800 SE Tiffany Ave. St. Port St.Lucie, FL 34952

Hospital Information:Type: Community Trauma Level: Number of Hospital Beds: 229Number of ED Beds: 30

EM Program Information: Phone: 772-398-1990Website: www.pbcgme.com Total Number of EM Residents: Residents to Attending Ratio Working Clinically: 1:1Accepts Medical Student Rotations? Yes, contact program for further details.

EM Program Curriculum: PGY 1: Critical Care, Ortho, Pediatrics, EM, Internal Medicine, Cardiology, General Surgery, GS/EM, OBPGY 2: EM, Pediatrics, Trauma, Second Site: EM, RadiologyPGY 3: Ortho/ENT, EM, Pediatrics, Elective, EMSPGY 4: Elective, EM, Trauma, Research/Administration, Pediatrics, Ortho, EMS, Toxicology, Second Site: EM

EM Program Application Information: Dates applications are accepted: SeptemberPrefers COMLEX Scores; Scores are variable based on candidateInterview Dates: October-DecemberLetters of Recommendations: Yes, contact program for specific number

Michigan: Physicians group seeking experienced, board-certifiedemergency medicine physicians. We are looking for candidates to join our expanding, well staffed team environment that offers a complete benefits package. Positions available are located in Southeast Michigan. For all inquiries, please contact Tressa Gardner at 810-845-8133, or email CV to [email protected]

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PUBLICATION: Pulse Magazine - April 2012 Norcom Inc. 847-948-7762SIZE: Qtr. Page Ad - B/W [email protected]

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J. David Keitz, D.O., FAWM, DiMMFirefighter, Emergency Medicine Physicians

Diploma in Mountain Medicine Coming to the United States

As avid climber, struggling through emer-gency medicine proved to be a challenge. Combining my love of medicine and the outdoors naturally led me to many wil-derness medicine courses, but I was look-ing for something more challenging than the typical continuing education meeting. Then I found the Diploma in Mountain Medicine course in the UK, and miracu-lously my residency director let me attend. I found myself in the most comprehensive mountain medicine course offered in the world.

The diploma course is credentialed by sev-eral organizations: the International Society of Mountain Medicine, The International

Mountaineering and Climbing Federation (UIAA), The International Commission for Alpine Rescue (ICAR) and local uni-versities in each country. The new Diploma course in the US is co-sponsored by the Universities of Colorado and Utah.

Not only are the courses rigorous academi-cally but you will find yourself in amazing mountain environments learning naviga-tion, search and rescue, avalanche safety, glacier travel and more. The goal is to be proficient in negotiating the alpine envi-ronment and to competently manage the injuries and illnesses one may encounter there making this the premier training experience for the Physician, Nurse or

Medic who wishes to be a qualified expedi-tion medical officer.

The course is divided into four sessions, two mostly academic that coincide with the Wilderness Medical Society’s Winter and Summer meetings, and can be completed in one or two years. The field sessions will occur in Mount Rainier National Park or Wasatch National Forest. One can simulta-neously earn CME and credits towards the Wilderness Medical Society’s Fellowship in Wilderness Medicine.

For more information and to register see http://www.wms.org/education/dimm


Irrigation under pressure is arguably the most important element of wound care. Reducing bacterial and foreign body load improves infection risk and promotes a better cosmetic result. This ultimately improves outcomes, reduces healthcare costs, and increases patient satisfaction.

Typically, irrigation under pressure is accomplished by utilizing a 10-35 mL syringe and an 18-gauge needle. The clinician’s challenge is to effectively irrigate the wound without aerosolizing blood and debris that can potentially expose them or other staff members to blood born pathogens.

There are several commercial devices available which reduce the provider’s splash risk. Unfortunately, these devices come at a price, and not all emergency departments stock them. Several texts recommend puncturing a medicine cup with an 18-gauge needle and using this to irrigate the wound. This can shatter the medicine cup, further placing the patient at risk of retaining a foreign body. Additionally, this method may not be well tolerated by anxious or non-compliant patients, children in particular. Finally, this method further exposes the provider to a needle stick.

An alternative exists which is readily available in virtually every emergency department. It requires only an 18-gauge

P. Marvin Pustinger, D.O.PGY-IV Emergency Medicine Resident

Tricks of the Trade: Wound Irrigation

angiocatheter, a Vacutainer® one use holder by BD (or like), and a 10 ml syringe. The angiocatheter is not sharp which can be demonstrated to anxious patients and children. Preferably, the Vacutainer® should be the larger size used for blood cultures. An additional benefit of the Vacutainer® is that is that it is translucent, and the irrigation can be visualized.

To assemble, remove the stylet from the angiocatheter and secure to the syringe leur lock. Slip the tip of the angiocatheter through the hole of the Vacutainer®. Place the Vacutainer® against the patient’s skin and irrigate as you normally would. The Vacutainer® can remain in place over the wound while you refill the syringe.

This method allows the provider to irrigate the wound under pressure while directly observing their progress, reduces the risk of aerosolizing or splashing blood born pathogens and is readily available in the emergency department.

Members in the News!Congratulations to John Casey, DO who was honored as a Champion of Change by President Obama’s “Winning the Future” initiative for his role in advocacy and education surrounding the Affordable Care Act. Casey, the

Chief Resident at Doctors Hospital in Columbus, was selected by the Office of Public Engagement, in partnership with the Department of Health and Human Services as a person who embodies the initiative’s goals of “Innovate, Educate and

Build.” Dr. Casey’s work through the AOA and ACOEP has made a significant difference in the lives of many and we are very proud of him for this outstanding honor. Congratulations and thank you for your hard work!


In My OpinionWayne T. Jones, D.O., FACOEPAssistant Editor

The Monkey and the CatJean de La Fontaine was a 17th French poet who authored several works, including a series of fables which focused on human nature and interpersonal interaction. While taken for children’s stories, these works really examined the human moral fabric we see strung throughout society.

La Fontaine often looked at the injustices forced on others. One poem describes how kings would send a prince to faraway lands to deliver the king’s message. The prince would experience the wrath of the people and “burn their fingers to bring more power to some mightier king.” Using the same analogy in his fable, the story goes something like this:

Bertrand the monkey and Ratter the cat shared a dwelling, at all times, getting themselves into trouble. One day Bertrand noticed chestnuts roasting in the fire. He complements Ratter on the length of his claws. “Brother, this day you shall achieve your master stroke; you shall snatch some chestnuts out of the fire for me. Providence has not fitted me for that sort of game. If it had, I assure you chestnuts would be a fine time.”

Though Ratter knew the fire was hot, he reached into the embers and recovered the chestnuts one at a time, and with each swipe of his paw, he was burned. Bertrand ate the nuts as they rolled out, complimenting Ratter. Ratter never enjoyed the chestnuts, only to mend his wounds from the ordeal.

So who perpetrated the crime? Was it Bertrand the monkey? He planned the whole endeavor. Was it Ratter, since it was his paw that executed the crime? Remember, Ratter never benefited from the partnership.

This interaction has been adopted by the legal system and dubbed “Cats Paw Liability,” which describes the nature of how courts allocate liability, specifically in disputes regarding dismissal of employees for various, possibly unscrupulous, reasons. In other words, human resources may fire an employee on the recommendation of an immediate supervisor, but the human resources department accepts all responsibility related to employee discrimination, regardless if they investigate the reason for termination or not. In other words, they can get burned for another’s decision.

However, outside of human resources, this trail of responsibility does not always follow. Take for example the rules imposed by insurers on healthcare coverage. Aunt Millie may be ill, but unless she meets InterQual Admission Requirements, she must be discharged (or placed in some outpatient status). Hospitals do not make much, if anything, on outpatient bedded patients and summarily push the ED to discharge these patients. With shrinking healthcare dollars, the push to discharge is intensifying.

Who wants the patients discharged? Not you, you wanted to admit Aunt Millie. The hospital? Well, only because the insurance won’t pay. Ok, so who is Bertrand and who is Ratter? Who will get burned? I would not rely on cat’s paw liability to involve the insurer. Maybe the hospital will become involved, but for different reasons. La Fontaine’s fable is as true today as it was over 400 years ago. My caution here is to be careful and not fall to pressures of “insurance and payment,” but to make appropriate patient care decisions. You are the physician, not the cat’s paw.

AOBEM Announcement about CAQsAOBEM currently offers three Certificates of Added Qualifications(CAQs) to quali-fied emergency medicine physicians. The CAQs are: Toxicology, Emergency Medicine Services, and Sports Medicine. The practice track for these CAQs have been closed for years and there are two CAQs that will have their clinical pathways to certification closing in the near future. AOBEM is not a member of the conjoint committees for these CAQs, therefore, AOBEM-boarded physicians can only

qualify to take the exam while the clinical pathway is open.

The clinical pathway for Underseas and Hyperbaric Medicine is closing at the end of 2012. The contact information is:

American Osteopathic Conjoint Committee of Undersea and Hyperbaric Medicine, 142 East Ontario Street, Flr 4, Chicago, Illinois 60611 Phone 800-621-1773, Ext 8229 - Fax 312-202-8495.

The clinical pathway for Hospice and Palliative Medicine is closing at the end of 2013. Interested applicants must meet specific requirements found on the American Osteopathic Conjoint Committee of Hospice and Palliative Medicine's web site www.aochpm.org. Or, for further information please call: (800) 621-1773, ext. 8195


Life Happens

Nova Southeastern Welcomes ACOEP Presidents

Carly Snyder, D.O.PGY IVResidency is an interesting time in the life of a physician. It comes with many challenges, some that you can plan for or even expect, and others that just take you by surprise. Currently, I’m a 4th year resident at Albert Einstein Medical Center in Philadelphia, PA, getting ready to sit for my board exam in March and subsequently start my life as an attending emergency physician in July. I can say with certainty that residency did not go exactly as I had planned, but does life ever go as planned? I think the good majority of emergency medicine residents,( i.e. type A personalities with a side of ADD) go into residency expecting it to be academically stimulating and challenging, to spend a lot of time working, and to constantly feel exhausted. No matter what you plan for, residency does all of those things and then some. I try my best to mentor my junior residents with this simple phrase, “Life happens in residency.” Just because we happen to be in residency and often times are unavailable to our family and friends, it doesn’t mean they stop their lives to wait for us to finish our training. Friends and family have parties, reunions, or weddings, vacations, have regular weekends off, sleep eight hours a night, have a steady gym schedule, get sick – sadly, many of us may lose a family

member or close friend during training. We study whenever we can, read articles, listen to EM-Rap and try to do right by our patients. Being a resident, you are constantly focused on becoming the best physician that you can be. Many times we lose ourselves in the process, lose focus on our own health and well-being. My intern year began while my grandmother was dying of lung cancer. This was not exactly how I saw myself starting residency, but I took it in stride. I continued working my crazy hours and spending every moment I could driving two hours home just to give her one more hug or have her tell me a story. She died during November of my intern year. Why do I tell you this? Well, because I had to do something that we all have to do; go on with residency. As residency progressed I lost two aunts and an uncle. I watched many classmates lose family, aunts, uncles and even a father. No one coaches you in med school or even residency on how to deal with these types of deep personal losses, I don’t think anyone can. Somehow, as physicians and especially ED physician, we can put on our game face and make it through. Life happens, residency keeps right going, and so do we.In December of intern year, I met my husband. He was exactly what I needed

to keep myself motivated and focused on my future. We became engaged during my 2nd year and married during my 3rd year. He helped me to remember to think about myself and my family. We, as residents, definitely do not do that enough. He knew how important exercise and good physical health were to me and encouraged me to stay active and to take care of myself as well as my patients. A lot of life happened during the past three years and eight months. It’s been one crazy ride and I can say without a doubt that it’s been worth every minute. The friendships you make and bonds you build during this very crazy time in our lives is absolutely incredible. Residency is not easy, but we’ve all figured out a way to make it through, together. Life happens during residency and I wouldn’t have it any other way. These experiences, whether good or bad, shape who we become as people and as physicians. Sure, there are things we all wish we could change, but if you did change that one thing, would you still be who you are today? What I do know is that I feel privileged to be in an emergency medicine resident on the way to completing my training, growing into a person and physician I am proud to be, and ready for whatever the future may bring.

by Ashley Guthrie, OMS II

This February, Nova Southeastern’s College of Osteopathic Medicine Emergency Medicine Club welcomed not one, but three ACOEP presidents. ACOEP President Gregory Christiansen DO, M.ED, FACOEP, ACOEP, Residency Chapter president Dr. Justin Arnold DO, MPH, and ACOEP Student Chapter presi-dent Joe Sorber OMS III, addressed a group of hopeful first and second year

Emergency Medicine students.

Students were afforded the opportunity to learn about the benefits of being a student member in the ACOEP, which include the brand new mentorship program, podcasts, and twice yearly conferences. The confer-ences alone make being a student member well worth the membership. The confer-ences entail the residency fair, lectures, labs, and the leadership academy, which becomes a part of the Deans letter upon graduation, free to student members.

Dr. Christiansen especially stressed the

importance of students being involved on a national level in order to help shape the future of emergency medicine. Students learned how easy the ACOEP makes being involved with numerous student chap-ter board positions that can be attained through a voting process at the Emergency Medicine fall conference held yearly. Overall, the most important thing that students learned from the presentations was that being a member of the ACOEP means being part of a caring organization with a legion of leaders that care about them and their future.


Why I took the Pledge Plunge (and why you should too!)

Stephanie Whitmer

For those of you who do not know me, my name is Stephanie Whitmer and I am the Director of Development for both ACOEP and FOEM. I am 26 years old and have never given any significant charitable contribution in my life. However, that will change in 2012 as I pledge to give $500.00 annually to the Foundation for Osteopathic Emergency Medicine. I think sometimes it helps to get a peek behind the scenes to understand the true character of a charitable organization, and so I would like to share why I have decided to make this commitment.

I work directly with the residents, my heroes. Because one of my responsi-bilities is to coordinate the Foundation’s Resident Research Competitions, I have the unique advantage of getting to know these residents quite well. And let me tell you, these young physicians are nothing short of remarkable when it comes to dedi-cation to their work. I have never worked with a more enthusiastic or meticulous group of people in my life, and it is truly my pleasure to get to know each and every one of them year after year. Although com-petition season means my phone will be ringing off the hook with questions, I cher-ish the fact that I get to be the one to help them take that next step as a researcher. If making a pledge to FOEM means showing my support to these inspirational individu-als, then that is what I am going to do.

The FOEM Board never ceases to amaze me. I am also lucky enough to work on a daily basis with the dauntingly talent-ed members of the FOEM Board. When applying for their positions on the Board, some of their CVs were too heavy to lift, so you can imagine the level of experience they bring with them. While most of these volunteers are also ER physicians, CEOs of companies, and active members of various other committees, I can honestly say that every single member of the FOEM Board pulls their weight to guarantee the success of the Foundation. It is my pleasure to fol-

low the example of the FOEM Board and make my $500.00 annual pledge.

I care about the future. The Foundation for Osteopathic Emergency Physicians has only just begun their path of improving patient care through research and educa-tion. Although the Foundation already boasts five resident research competitions, four grant programs, and a variety of other fun events, the Board has been actively working to broaden the range of opportunities to benefit the members of ACOEP and beyond. At their Strategic Planning Retreat in February, the Board came up with several innovative methods of fulfilling the Foundation’s mission, from faculty development training, to residency program start-up funds. However, these ideas will never become a reality if we do

not stand behind FOEM financially. I am taking that first step and hope you will too.It is my wish that this personal perspec-tive on the Foundation for Osteopathic Emergency Medicine has shown you what an amazing organization this is and what potential it has for the members of ACOEP. FOEM needs your support now more than ever, so please follow my example as I have followed the example of those before me. Pledges are deducted automatically at the intervals and amounts you determine. A quarterly pledge of just $125.00 amounts to $2,500.00 in five years. It’s that easy to make a significant impact! To begin a conversation about the FOEM Pledge Program or to sign up, please go to www.foem.org or contact me directly at 312-445-5712, or at [email protected].

West Virginia: Charleston – BP/BC EM physician opportunity within academic environment. This three-hospital system has 100,000 annual

ED visits and includes a Level 1 facility. There are numerous allopathic & osteopathic residencies including a solidly established Emergency Medicine Residency Program. Equity-ownership group provides outstanding package

including family medical, employer-funded pension, CME, malpractice, plus shareholder status at one year with no buy-in.

CHARLESTON, WEST VIRGINIAOPPORTUNITY

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CMS Measure OP-15: Attempting to Decrease Head CT Utilization

The marriage of quality and efficiency is facing increasing pressure in healthcare. The ultimate goals to align incentives of hospitals, providers and payors in order to improve quality and outcomes, reduce errors and decrease costs. Most would agree that this is necessary to transform our healthcare system to provide services for decades to come. This is not with-out significant challenges and debate, and undoubtedly miscalculations will be made in this search.

The most recent controversy in emergency medicine may be the CMS Measure OP-15 : Use of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic Headache. This is a mea-sure designed, in theory, to cut down on unnecessary head CT’s, which can decrease cost and reduce radiation exposure. We all know that a significant number of the head CT’s we order do not change the management of the patient. This seams a worthwhile goal.

A few problems arise with the methodology used by CMS to determine the necessity of CT scanning for the atraumatic headache patient. First, they use the Medicare bill-ing data as the information to obtain the numerator and denominator for the mea-sure. Most often, the indication for which the physician believes the CT is necessary is contained in the history of present illness, past medical history, exam or medical deci-sion making portion of the patient chart and not coded on the diagnosis line.

Dizziness, paresthesia, lack of coordina-tion, lumbar puncture, subarachnoid hem-orrhage, complicated or thunderclap head-ache, focal neurological deficit, pregnancy,

trauma, HIV, and tumor or mass, are the denominator exclusions. Admission to the hospital is also an exclusion criteria for this measure. Unless this is included on the diagnosis line in the chart, it will not be identified and the CT may be deemed unnecessary.

A recent original research article published online in Annals of Emergency Medicine, by Schuur, et. al. concluded “The CMS imaging efficiency measure for brain CT’s (OP-15) is not reliable, valid or accurate and may produce misleading information about hospital ED performance.” The results demonstrated the measure’s accu-racy was 16.7%. The studies authors stated that there is a potential for negative unintended consequences. Pressure on providers to decrease CT’s on higher risk elderly patients would certainly qualify. They also commented that this measure would be ripe for “gaming” in which physi-cians and coders would adapt their coding to meet the measure without really chang-ing practice, which would defeat the whole underlying purpose of the measure.

The problem with a measure such as OP-15, which has been shown to be inac-curate, is that as a publicly reported mea-sure, it may sway the unknowing public away from a hospital for which the data appears inferior to other hospitals. This provides even more incentive for a hospital to game the system to maintain market share in a competitive marketplace.

Developing validated clinical decision guidelines should remain a high priority in emergency medicine. This has been helpful to reduce radiation usage in other conditions we treat such as Ottawa rules

in ankle and knee injuries. Guidelines to provide decision support in pulmonary embolism, chest pain, and pneumonia exist and are helpful but not infallible.

Overall utilization measurement to identify outlier physician practice patterns may be more useful and can identify those provid-ers who are practicing outside the norm. This in turn can lead to more efficient practice of emergency medicine. National benchmarks exist to help identify outlying providers in your practice.

Close scrutiny over future proposed CMS guidelines must be continued to avoid this pitfall. CMS will undoubtedly bring forth other measures in the future, which may have similar limitations. We as emergency physicians must stay informed and vocal on these issues to make sure the measures introduced and other healthcare changes actually do what they are intended to do, which is, improve the quality of healthcare delivered at a more reasonable cost.

by Jeremy D. Tucker, D.O.

AOA President Martin Levine, DO, presents ACOEP Executive Director Jan Wachtler and ACOEP President Elect Mark Mitchell, DO, FACOEP with a certificate recognizing ACOEP as a specialty affiliate.


proposed dates.

The ACOEP Board of Directors has not been silent regarding this issue. It has been fruitless for osteopathic physicians not trained in ACGME-accredited programs to attempt to contact the ACGME directly as our responses of concern have been met with silence. This knowledge prompted the aforementioned letters to CORD, ACEP and AAEM asking them to support the ACOEP disapproval of the enactment of these impact statements. Furthermore, osteopathic program directors have contacted ACGME program directors and asked them to contact ACGME regarding their disagreement with these statements.

There is another issue that the ACGME has set forth that involves faculty association with ACGME-accredited training programs. The goal of the ACGME is to prevent osteopathic physicians from being faculty members in residency programs if they did not complete an ACGME-accredited residency. I believe this particular goal will eventually eradicate osteopathic physicians from practicing medicine in academic institutions.

ACOEP has the support of many physicians in the allopathic world, and it is our hope that the ACGME will heed their voices of displeasure regarding these impact statements. The Board of Directors of ACOEP as well as all AOA-accredited training programs seek equal acceptance for our graduating residents when it comes to entering ACGME-accredited fellowships. We also believe that physicians trained in AOA-accredited programs have the ability to be faculty members in ACGME-accredited programs.

This is the latest information that is available regarding the ACGME and their intent. It is an evolving issue, and I believe by no means set in stone. The ACOEP board will continue to monitor what is transpiring and update the membership when anything of importance occurs.

permanently closing the door for a resident graduating from an AOA-accredited residency to enter a fellowship in an ACGME program. This is verified by the next Impact Statement:

Requirement Revision:III.A.3. Prerequisite clinical education for entry into ACGME-accredited fellowship programs must meet the following qualifications:III.A.3.a) for fellowship programs that require completion of a residency program, the completion of an ACGME-accredited residency program or an RCPSC-accredited residency program located in Canada.III.A.3.a) for fellowship programs that require completion of some clinical education, clinical education that is accomplished in ACGME-accredited residency programs or RCPSC-accredited residency programs located in Canada. These statements will become effective July 1, 2015.

This will have serious consequences for all AOA-accredited training programs as there will not be a conduit from our programs to ACGME-accredited fellowship programs. Graduating residents of AOA-accredited programs will not have access to most fellowships offered in the United States. It may seem that since these statements do not take place for a few years that there is time to attempt to amend these changes. Our osteopathic students are aware of these changes, and it has already affected their determination of which residency programs offer them the best education. As a program director, I had many candidates question me during this current interview season as to what they should do since they were considering entering fellowships. It was extremely difficult to inform prospective candidates that they should seek their residency training in ACGME programs. I had to be honest and explain that if they truly want to enter a fellowship then my program was not for them. The osteopathic profession will lose many exceptional residents with these impact statements taking place on their

ACGME Impact Statements and their Effects on Osteopathic Training Programs

As many of you may be aware, the ACGME has published its Focused Revision of the Common Program Requirements. The proposed statements will have a direct negative bearing on osteopathic training programs. Implementation will begin as early as 2014 and it is vital to update the ACOEP membership as to what is happening, what effect these statements will have on osteopathic residency programs, and what ACOEP has done to seek help from the other houses of emergency medicine.

The ACOEP Board of Directors was made aware of these revisions in the middle of November and had minimal time to react. The AOA asked ACOEP to “sign-on” to their response letter to ACGME; however, our board felt that the tone of the AOA letter was too harsh and a more reasonable approach was needed to handle this situation. ACOEP board members reached out to our counterparts in emergency medicine; CORD. ACEP and AAEM responded to the ACGME by expressing their concerns regarding the impact statements. We sent letters of appreciation to these organizations for their support of the osteopathic profession and training programs.

The ACGME Impact Statements read:

Requirement Revision:III.A.2. Prerequisite clinical education for entry into ACGME-accredited residency programs must be accomplished in ACGME-accredited residency programs or Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited residency programs located in Canada. This will become effective July 1, 2014.

It is evident that all osteopathic programs have been excluded from this statement. At an initial glance, this may not seem very deleterious to our profession as many osteopathic medical students now enter ACGME-accredited residencies instead of AOA-accredited programs. However, this impact statement leads the way to

John C. Prestosh, D.O., FACOEPSecretary, ACOEP Board of Directors


the validity of the certificate for another 10 years, the diplomat must complete the OCC process.

The Value of OCCSpecialized residency training and initial board certification established initial standards for performance, but did not assure maintenance of proficiency over a practice lifetime. Regulatory agencies, health maintenance organizations, and the community require reassurance and documentation of continual professional development and education by physicians. OCC is a professional response to the need for public accountability and transparency. AOBEM believes high standards for certified emergency physicians lead to better health care for emergency patients. The principles behind OCC are designed to assure that the highest standards of patient care are practiced and maintained and to assure patients, physicians, and other stakeholders that physicians are being continually assessed and continually improving patient care. This is congruent with AOBEM’s mission to protect the public by ensuring the excellence of osteopathic emergency physicians.

The Federation of State Medical Licensing Boards (FSMB) recently approved language that would allow OCC participation to serve as a proxy for state-based Maintenance of Licensure (MOL). The Joint Commission strongly encourages hospitals to measure the six core competencies of their medical staff every two years as part of the credentialing process. In the future, the OCC program may help fulfill Joint Commission requirements. Some pay-for-performance models reward physicians for ongoing performance evaluation and evidence of involvement in improvement.

The AOBEM OCC process offers physicians a program to keep skills and knowledge current in a rapidly changing field. It also responds to the healthcare consumers who demand evidence of a physician’s ongoing excellence in the field of Emergency Medicine.

your peers are the best judge of your ability to practice emergency medicine, not governmental bureaucrats; therefore, we have progressed from certifying your training to certifying your competence. We have tried our best to do so in a way that is realistic- through education (the COLAS, for example), through cognitive testing (the written examination), and through demonstration of practice (the oral examination). The additional requirements of OCC are in keeping with the demands of the public, and with AOBEM's philosophy. We trust that you will continue to support the concept that your peers must remain the ultimate judges of your competency, not a state or federal governmental agency .

About Osteopathic Continuous Certification (OCC)

OCC embodies the principles of lifelong learning and continuous improvement designed for the benefit of the public and the profession. The goal of OCC is to continually set the standards of excellence in the field of Emergency Medicine by focusing on the six core competencies integral to quality medical care: medical knowledge, patient care, interpersonal/communication skills, professionalism, practice based learning and improvement, and systems-based practice. These competencies were established by the American Osteopathic Association (AOA), the certifying organization for the American Osteopathic Board of Emergency Medicine (AOBEM) and the other 17 osteopathic medical specialties.

The History of OCCThe practice of Emergency Medicine has changed dramatically since its founding in 1980. What began as a one-time assessment to obtain a lifetime certificate has evolved into a lifelong learning assessment and continuous certification. Every certificate issued by AOBEM since 1992 is valid for 10 years and expires on December 31 of the tenth year. In order to maintain

OSTEOPATHIC CONTINUOUS CERTIFICATION

Many emergency physicians have expressed emotions ranging from consternation, to frustration, to anger at the ever-expanding requirements for certification in our specialty (and it is little comfort to know that physicians in other specialties share the same feelings). A brief review of the history of certification in the relatively young specialty of emergency medicine certainly validates the belief that more and more is required of us to achieve and maintain the status of "Board Certified." 35 years ago, one could become "certified for life" via a practice pathway and passing a two-part examination. Then the practice track was closed, and certification could only be achieved after three years of post-graduate training. Soon the requirement became four years of training, and a three-part examination. Following that, life-time certification was replaced by 10 year certification cycles, requiring COLA modules and a two part formal recertification examination. And now we have the introduction of OCC (Osteopathic Continuous Certification), which adds further requirements to the list. Physicians are understandably concerned and asking, what is driving force behind these changes? The answer to that question is as follows: The driving force behind these changes is the demand by the public (often represented by politically powerful organizations) and governmental agencies that practicing physicians demonstrate both initial and continuing competence in the specialty in which they practice. There is no escaping this demand, and as many of you are aware, the Centers for Medicaid and Medicare Services are in the process of attaching fiscal ties to these demands in the form of "pay for performance." There is an additional demand implicit from governmental agencies to certification boards- either you assure competence in your diplomats, or we will take over that process.

We at AOBEM strongly believe that

Mark Stone D.O.Secretary, AOBEM


OCC ComponentsThe AOBEM OCC process is designed to document that emergency physicians certified by AOBEM are maintaining the skills and knowledge necessary to provide quality patient care. The program gives diplomats the opportunity to demonstrate to peers, patients and the general public a commitment to lifelong learning and improvement in their practice of Emergency Medicine.

OCC acknowledges that diplomats have already demonstrated a commitment to excellence by becoming certified and builds upon this. OCC incorporates six core competencies, as defined by the AOA, into an evaluation process by which emergency physicians can document their ongoing commitment to excellent patient care.

The Six Core CompetenciesPatient Care: provide care that is compassionate, appropriate, and effective treatmentMedical Knowledge: demonstrate knowledge about established and evolving diagnostics and treatmentsInterpersonal and Communication Skills: demonstrate skills that result in effective information gathering and transmission to patients, their families and professional associates.Professionalism: demonstrate a commitment to carrying out professional responsibilities, adhering to the AOA Code of Ethics, and sensitivity to diverse patient populations.Systems Based Practice: demonstrate awareness of and responsibility to larger context and ability to use system resources to provide optimal care (e.g., coordinating care across multiple specialties, professions, or sites).Practice Based Learning and Improvement: able to investigate and evaluate their patient care, collect scientific evidence and improve their practice of medicine.

The Four Part Process of AOBEM OCC1. Professional Status: Emergency physicians must hold a valid, unrestricted and unqualified medical license in the states where they practice or in any one state if in active military practice. Diplomats must

also maintain continuous membership in good standing in the American Osteopathic Association. Such membership insures that a physician meets the AOA’s Continuing Medical Education (CME) requirements for certification and adheres to the AOD Code of Ethics.2. Continuous Osteopathic Learning Assessment (COLA): A COLA module involves reading assigned articles from the literature and then completing an on-line examination concerning those articles. The list of assigned articles and applications for the examination are posted on the AOBEM website. A new COLA module is available each year. In order to be eligible for the Formal Re-Certification Examination (FRCE), a diplomat must take a minimum of 8 COLA modules within a 10 year cycle. Additionally, the diplomat must receive a passing score on at least 6 of the COLA modules. Taking and passing 6 COLA modules will not satisfy the requirement, as the physician must have attempted at least 8 COLA modules. Beginning in 2012 (those diplomats who will be taking the FRCE in 2020), diplomats must take and PASS at least 8 COLA modules. Each COLA module is available on-line for 3 years only. Diplomats have access only to those modules that are available on-line; thus, it is important that physicians keep current with each of the modules. Candidates have an initial 3 opportunities to successfully pass a COLA module. If unsuccessful after these initial 3 attempts, the candidate may pay the COLA fee again. She/he then has another 3 opportunities to pass the module.

DIPLOMATS WHO FAIL TO MEET THE COLA REQUIREMENTS FOR THE FRCE, WILL NOT BE PERMITTED TO TAKE THE FRCE. THEY MUST THEN RE-ENTER THE CERTIFICATION PROCESS AND COMPLETE IT IN ITS ENTIRETY (PART 1, PART 2, AND PART 3 OF THE PRIMARY CERTIFICATION PROCESS). THESE DIPLOMATS WOULD MAINTAIN THEIR CURRENT CERTIFICATION UNTIL IT EXPIRES; HOWEVER, TO BECOME “RE-CERTIFIED” THE PHYSICIAN MUST RE-ENTER AND COMPLETE THE ENTIRE PRIMARY CERTIFICATION PROCESS.

3. Formal Re-Certification Examination (FRCE): The entire Table of Specificity and its core content will be covered in the FRCE. Diplomats are required to take this examination every 10 years to maintain Osteopathic Continuous Certification. The examination consists of a computer based multiple choice examination as well as an oral examination. AOBEM believes the oral examination is an important component of the OCC process. A "face-to-face" interaction is the best method for evaluating physician knowledge, patient care, professionalism, interpersonal skills/communication, and systems based practices. Thus, the oral examination fulfills 5 of the 6 Core Competencies. It should be noted that diplomats may take the FRCE as early as 2 years prior to the expiration of their certificate. Diplomats also have a maximum of 2 years after the expiration of their certificate to successfully complete the FRCE. Failure to successfully complete the FRCE will require the physician to re-enter the certification process in its entirety (Part 1, Part 2, and Part 3).

4. Practice Performance: Beginning in 2013, diplomats will need to perform a practice assessment as a part of the Osteopathic Continuous Certification. AOBEM’s practice performance component requires the physician to identify an area of emergency medicine that has comparison data and improvement that can be measured. The diplomat reviews at least 10 charts from their department, including at least 3 of their own charts. The diplomat then evaluates the care and compares it to national standards or expert consensus guidelines. This information is then used to come to a plan to improve care by a change in process or education. Once this plan is implemented, another 10 charts are reviewed and evaluated for improvement in care. The physician will need to complete a form detailing their project - no charts will need to be submitted.


Looking Ahead to Scientific Assembly

It’s not too early to start thinking about the fall! ACOEP’s Scientific Assembly, which takes place October 14-17, 2012 at the beautiful Sheraton Denver Downtown, will feature world-renowned experts, presenting the very latest in technology, treatment and tips! The all-star line-up features:

Richard Bukata, MD will kick off the conference as the featured keynote speaker. Dr. Bukata is a graduate of the Emergency Medicine residency at the University of

Southern California at the Los Angeles County Medical Center. He started Emergency Medical Abstracts which reviews 600 journals a month, providing paper abstracts, audio summaries and commentary. He has led over 400 evidence-based courses, focusing on medical literature. Dr. Bukata is the co-founder of the National Emergency Medicine Board Review and is a recipient of the ACEP Education Award.

Diane M. Birnbaumer, M.D., FACEP, Professor of Medicine at the David Geffen School of Medicine at UCLA and Senior Faculty member in the Department of Emergency Medicine at

Harbor-UCLA Medical Center, will give two expert presentations; Abdominal Pain in the Elderly and TIAs: Myths and Controversies. She has given over 2000 lectures in her career locally, nationally and internationally and received the ACEP Outstanding Speaker of the Year Award and the Outstanding Contribution to Education Award.

Michael Epter, DO, FAAEM presenting, “Deadly Headache Disasters You Can’t Miss!” and “You Can Teach on the Run! Effective Strategies for Teaching in a Busy Emergency Department.” Dr.

Epter is an Associate Professor at the University of Nevada, where he serves as the Vice Chair of Education and Residency Program Director for the Department of Emergency Medicine. He has received numerous accolades and awards for his work as a speaker, a program director, an educator, and is heavily involved in AAEM, CORD, and WestJem.

Andy Jagoda, MD, FACEP is a Chair in the Department of Emergency Medicine at the Mount Sinai School of Medicine and will speak on Traumatic

Brain Injury and Seizure Management in the ED. He has published extensively, serving as an author and coeditor for numerous books, studies, and magazines. A specialist in neurological emergencies, he has served in leadership roles in many national organizations including ACEP, the Brain Trauma Foundation, the National Institute of Neurologic Diseases and Stroke, the Foundation for Education and Research in Neurologic Emergencies. He also serves on the Brain Injury Advisory Board for Major League Baseball.

Kevin Klauer, DO, EJD presenting, “Important Papers from Recent Literature” along with Dr. Bukata. Dr. Klauer is Chief Medical Officer for Emergency M e d i c i n e

Physicians, Ltd. where he also serves on the Board of Directors, and is the Director of the Center for Emergency Medical Education (CEME). He is an Assistant Clinical Professor at Michigan State University College of Osteopathic Medicine and serves as Editor-in-Chief for Emergency Physicians Monthly, and is the coauthor of two risk management books. Dr. Klauer also serves as ACEP Council Vice Speaker and is on the Board of Directors for Physicians Specialty Limited Risk Retention Group.

Dr Mark Rosenberg, DO, MBA, FACEP, FACOEP-D is Chair of Emergency Medicine at St. Joseph's Healthcare System, and Chief of both Geriatric E m e r g e n c y Medicine and

Palliative Medicine. In Denver he will explore the challenges, opportunities and pitfalls of geriatric and palliative care in the ED. Among his many positions, Dr. Rosenberg is Chairman of the Geriatric Emergency Medicine Section of ACEP; Chairman and Founder of the Palliative Medicine Section of ACEP; and Board of Director of NJACEP. He has been a consultant to NQF and has worked with American Geriatric Society. He has published in many journals, and has three textbook chapters accepted for publication.

Registration information and speaker schedule are available on the ACOEP website!

Erin Sernoffsky


Editor Responds

I want to thank Dr. Fred Sabol for his letter to the Editor in the January 2012 – Pulse in response to my article in the October 2011 issue, “Mid-Level Providers-Are They a Blessing or a Curse in the Emergency Department?”

I could not agree more with Dr. Sabol that physician’s assistants and nurse practitio-ners are not a substitute for an Emergency Medicine Physician (EMP). Ideally, the Emergency Medicine Physician should be residency trained and board certified in Emergency Medicine. The supply of residency trained and board certified EMP does not meet the demand for EMP posi-tions in the United States. Many emer-gency departments are staffed by career emergency medicine physicians who are not residency trained or board certified in EM. These individuals trained in other specialties: family practice, internal medi-cine, surgery, anesthesia, etc. have pro-vided health care in the ED throughout the United States since the infancy of Emergency Medicine through the present.

I do not know the exact time line when mid levels made their debut in the ED, I have been working with them since 1990. I get the same complaints from the medi-cal staff at our hospital that the mid levels just order tests and have no idea of what is wrong with the patient or what is the patient’s differential. This is problematic and difficult to change secondary to the mid levels training and experience; how-ever, this can be rectified by having the

mid levels discuss all complex patients and any patients needing admissions with the attending EMP. What is interesting is the medical staff that complains the most about the mid levels are the ones who send their mid levels to see the patients in the ED. It is not uncommon for a member of the medical to refuse to talk to an ED mid level but it is okay for an EMP to talk to the specialist’s mid level.

What is mid level supervision? Is it signing off on a chart or is it actually seeing every patient seen by the mid level? In the former scenario, the charts are signed off without the physician actually seeing the patient. There is no consistency in how this is done or by whom. Is it signed for billing purpos-es, company policy and/or hospital or state licensing requirements? Unfortunately, this can create a legal liability for the phy-sician if there is a malpractice suit. In my experience, the physician is named in the suit even though the EMP did not have any knowledge of the patient. Is this the price of doing business or is it a liability that the EMP should avoid? In the later scenario, the EMP discusses every case or sees every patient that the mid level sees. If the EMP acknowledges every mid level patient either by evaluating independently or discuss-ing the case with the mid level creates, in my opinion, an unnecessary amount of the work for the EMP. And, why would a mid level take a job in the ED if they cannot practice independently within the parameters that are defined when the mid level is hired. A 100% case review would

be warranted when hiring a recent graduate or a new midlevel to emergency medicine. The mid levels should be able to practice independently and “supervised” only when the patient requires a higher level of care or complexity.

ED metrics such as turnaround times, door to provider, ED length of stay, patients per hour, RUVs generated per hour, patient complaints, code of conduct and adher-ence to CMS indicators are part of being an emergency physician and are reported in our biannual OPPEs. Patient safety is paramount as is treating our patients as how we would want to be treated. In my opinion mid levels can practice safe medi-cine if the mid levels are properly oriented, their roles and expectations defined (mid levels only see lower acuity patients and any complex patients must be seen in conjunction with the EMP attending) and adequately trained.

Would I want to work in an emergency department without mid levels? No, I realize there are many downsides to mid levels: different training, increased liability, increased paper work, resistance to mid levels by the medical staff and the refusal of patients to see a mid level when the patient feels they are entitled to see a doctor. These shortcomings aside, I enjoy working with nurse practitioners and physician assistants and will continue to support their role in emergency medicine.

Drew A. Koch, D.O., FACOEP-D

The following ethical dilemma was referred to us by an Emergency Department RN.

EMS calls in stating they are in the home of a 13 year-old female who called 911 because she has a sore throat. There is no family present and they cannot be reached. Consequently, there is no consent

Bernard Heilicser, D.O., MS, FACEP, FACOEP

What Would You Do?for transport of this minor patient (with a minor complaint). Should EMS transport this patient to the hospital?

You are medical control. What would you do?

Please send your thoughts and ideas to

fax 708-915-2743. Every attempt will be made to publish them when we review this case in the next issue. If you have any cases in your practice that you would like to present or have reviewed in The Pulse, please fax them to us.


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PAIDChicago, IL

Permit No. 2177

142 E. Ontario StreetSuite 1500Chicago, Illinios 60611

Emergency Physicians Medical Group (EPMG) is currently interviewing qualified physician candidates for positions throughout the Midwest. We care about what matters to our partners. That’s why we offer an exceptional compensation package and a work environment made up of talented and knowledgeable colleagues. It’s why we invest in your future through technology and a clear career plan. It’s why we believe in community, giving you the ability to have time to work and still have time to coach that weekly little league game. We care about more than just staffing shifts. We care about shifting expectations.

Contact us at 734 995 3764 or [email protected]. Visit us at www.epmgpc.com.

WE CARE ABOUTBEING THERE.

MICHIGANCommunity Health Ctr. of Branch CountyColdwater 25,000 volume

Mercy HospitalCadillac 20,000 volume

Lakeland Hospital St. Joseph 43,000 volume

DELAWARENanticoke Memorial HospitalSeaford 36,000 volume

I LL INOISRiverside Medical CenterKankakee 40,000 volume

IOWAMercy Medical Center – ClintonClinton 21,000 volume

PENNSYLVANIAMid-Valley HospitalPeckville 8,700 volume

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INDIANAFranciscan St. Anthony HealthMichigan City 30,000

gregory m. christiansen, d.o., m.ed., facoep doctor, do ... · icd 10 coding systems, drug...

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