NEWSLETTERNewsletter of the Society for Academic Emergency Medicine March/April 2004 Volume XVI, Number 2

PRESIDENT’S MESSAGE

Critical CareCertification: One (Giant) Step Back…

On December 23, 2003,SAEM was notified by theAmerican Board of EmergencyMedicine (ABEM) of two impor-tant decisions regarding criticalcare medicine (CCM) trainingand certification of emergency

medicine (EM) trained physicians. First, the AmericanBoard of Internal Medicine and the American Board ofPediatrics decided to continue to oppose any changeallowing EM trained physicians access to the U.S.(ACGME) certification process. Secondly, the InternalMedicine based programs – traditionally the site whereEM graduates were accepted and trained – will now shiftfrom requiring 75% to 100% of fellows be internal medi-cine trained before entry. These two decisions have creat-ed a professional exorcism for EM physicians alreadytrained in CCM and those seeking this training. ABEM hasinvested great effort and resources on this issue for overa decade – their work, while not producing the desiredresult, has been outstanding. Right now, ABEM has noviable options to reverse these decisions.

SAEM has long supported access of EM trained physi-cians into these programs and certification process. OurSociety, our Annual Meeting, and our journal have beenhavens for those EM CCM experts to share their views –beginning with the late Peter Safar, MD, and his manytrainees through the current pool of outstanding academ-ic EM intensivists. Much of our early and current recogni-tion comes from this support and the clear recognitionthat EM and CCM are inseparable – together, we care forthe sickest when needed and unplanned, and we createthe knowledge to improve the care of those patients.Optimal approaches to injured patients, patients with out-of-hospital cardiopulmonary arrest or sepsis – three of thelargest ‘CCM care categories’ – are central to the scientif-ic base of both EM and CCM (as well as other disciplines).The most important advances in each have been accom-plished with EM and CCM MD efforts – fluid resuscitation,neural protection (including cooling), drug therapy, earlyexternal cardiopulmonary support, and early goal directedsepsis therapy.

Donald M. Yealy, MD

(continued on next page)

SAEM NEWSLETTER

901 North

Washington Ave.

Lansing, MI

48906-5137

(517) 485-5484

saem@saem.org

www.saem.org

Research Fund Continues to GrowFrank Counselman, MDEastern Virginia Medical SchoolSAEM Financial Development Committee

Recently all SAEM members received the SAEM ResearchFund brochure. As outlined in the brochure, the goal of theResearch Fund is to raise sufficient monies to establish a researchendowment. The accrued interest from the endowment will fundcurrent and future research activities. These activities include thecurrent Research Grants, Institutional Research Training Grants,Scholarly Sabbatical Grants, the Medical Student Interest GroupGrants, and the Medical Student Research Grants, as well as sup-porting new research initiatives for the benefit of the membership.The May/June issue of the Newsletter will include the announce-ments of the 2004-2005 grant recipients. It will make you proud toread about the grant recipients that your Research Fund is helpingto support. Unlike other Emergency Medicine funding sources, ourfunds support research training grants.These grants are not direct-ed to a specific area of research and are open to all members.

Last year, 151 members and friends contributed over $42,000to the Fund. In addition, SAEM contributed $250,000. If you madea contribution last year, we thank you, and ask that you considermaking a similar or greater contribution this year. If you did nothave the opportunity to contribute last year, we encourage you tojoin your colleagues this year and make a generous donation.Challenge yourself, your colleagues and your alumni to meet orexceed the contributions made last year. One-hundred percent ofyour contributions go directly to the Fund; SAEM assumes all of theadministrative costs.Your donation is 100% tax deductible.You maypay by check (payable to “SAEM Research Fund”) and mail to theSAEM office or you can make a donation on-line through theSAEM website.

Call for Medical Student VolunteersThe Program Committee for SAEM is soliciting a request

for medical students who are interested in working at the 2004Annual Meeting in Orlando, Florida on May 16-19. TheProgram Committee will waive the registration fee for a limitednumber of medical students willing to assist with some admin-istrative duties. Each medical student will be responsible forcoordinating evaluations at assigned didactic sessions duringtwo half days and one luncheon session. The Annual Meetingprovides a unique opportunity for medical students to familiar-ize themselves with the research and educational interests ofemergency medicine. In return the students will receive a com-plimentary registration fee. Interested medical students shouldcontact Deborah Diercks, MD by e-maildbdiercks@ucdavis.edu with the a subject line labeled,“Medical Student Volunteer for Annual Meeting.”

2

Dr. Safar had a vision of a continuumof care – from the first recognition of ill-ness and injury (often the field), throughthe ED, ICU, hospital and return tohome. Combined training and collabora-tion were the keys to this chain of care.Now, decisions based on other needs orperceptions – seemingly ‘political’ ratherthan care or vision based – have threat-ened this evolution of EM CCM trainingand certification. Our challenge is not tolet the other part – the collaboration tocreate and disseminate the knowledgeof how to improve care – wither whileregrouping on the former.

Recognizing this, what should wedo? SAEM will continue to supportthose doing CCM work – trainedEM/CCM physicians and all others. OurSociety welcomes the knowledge, skillsand efforts, and will continue to be aplace to share, learn and grow. SAEMwill also continue dialogue with thosewho can help change the future – otherorganized medical groups and ABEM –recognizing that in the near future,progress will likely be small, if present.Our EM CCM physicians should contin-ue their excellence, and use this as a‘grass roots’ mechanism to reapproach

the issue, focusing on the accomplish-ments and the future rather than previ-ous decisions. Finally, all of us shouldconstructively share our thoughts withour colleagues locally who may beinvolved or could be involved - othernon-EM physicians and influentials – toeducate and enlist support. In manyways, this path – while involving farfewer people – parallels that of thestruggle EM faced and overcame 30+years ago. This is a big setback – but itdoes not change the reality of EM andCCM being ‘joined forever’.

President’s Message (Continued)

Competition for research funds is extremely stiff, and manysound proposals are not funded. Although the federal govern-ment is the largest single source of research funding, financialsupport is also offered by many agencies, foundations, andcorporations. The preparation of a well-written proposal andmeticulous planning are critical to successful grantsmanship. Itis also important to select an appropriate funding agency,since the investigator’s objectives must be consistent withthose of the funding organization. While most grant applica-tions have a number of similarities, each funding agency mayalso have unique requirements. Thus, applicants shouldscrupulously follow the application criteria of the agency orinstitution from which they are seeking support.

Many consider successful grantsmanship to be a reliablemarker of successful research development, and noviceresearchers look to more experienced researchers for guid-ance and advice regarding grant writing strategies. How wellan institution is funded is often correlated with the level ofexpertise in a given area of study. Thus, identifying projectsand investigators who are funded help familiarize us with thetypes of grants offered, respective areas of interest, and cen-ters of academic excellence.

Over the last three years, the SAEM Research Committeehas compiled a list of funded emergency medicine investiga-tors, which was first published in the SAEM January/February2002 Newsletter. Whereas many researchers in emergencymedicine serve as co-investigators or site investigators forresearch, we have chosen to list only principal investigators.Last year, the list included 48 NIH-funded projects (14 careerdevelopment awards and 34 project grants) and 10 non-NIHgrants. The current list includes 88 NIH-funded grants (19career development awards and 61 project grants) and 45 non-NIH grants. In addition to some projects that we overlookedlast year, the updated list includes the newly funded projectsbeginning in 2003, as well as 10 project grants that are termi-nating this year. Information regarding the NIH-funded projectsmay be obtained from the CRISP database available atwww.nih.gov.

Without a central database, non-NIH grants are significant-ly more difficult to identify. We compiled this list from an inter-net search of http://fdncenter.org, www.naicrc.org as well as

from word-of-mouth and self-report. As a result of an e-mailsent by Dr. Clifton Callaway last year to the members of SAEMwhich asked what sources of funding they were using at thetime, we were able to identify various non-NIH grant recipients.The Centers for Disease Control (CDC), Department ofDefense (DOD), Robert Wood Johnson Foundation (RWJF),and the Emergency Medical Services for Children program(EMSC) are all important, prestigious sources of largeresearch funding. Information regarding CDC-funded projectsis listed at www.cdc.gov/ncipc/res-opps/extra.htm, and detailsregarding RWJF projects are available at www.rwjf.org/pro-grams/grant.Detail. Created in October 2001, PECARN is thefirst federally funded national network for research inEmergency Medical Services for Children (EMSC). In June2001, the Health Resources and Services Administration(HRSA) and the Maternal and Child Health Bureau (MCHB)began to invite proposals from established clinical investiga-tors to participate in forming collaborative research partner-ships among various academic and community-based hospi-tals. For further details, please see the June 2003 issue ofAcademic Emergency Medicine (vol.10, no.6, pp. 661-668).

Other foundations that are currently funding researchers inemergency medicine include the American Heart Association(AHA), the American Geriatric Association (AGA), theAmerican Legacy Foundation, the William Penn Foundation,the Firearm Injury Center (FICAP), the Children’s HealthInsurance Project (CHIP), The Mayday Fund, HartfordFoundation/American Geriatric Society, the National Center forMedical Rehabilitation Research, and the Wallace CoulterFoundation. As there are numerous foundations that are inter-ested in providing financial support to researchers, it is incum-bent upon us to utilize these resources and further our spe-cialty’s research endeavors.

We hope to provide a more comprehensive list of whereresearchers in emergency medicine derive their funding and toultimately guide novice investigators towards successfulgrantsmanship. If you wish to provide information regardingyour own personal experience with grant writing or reviewing,please email your contact information to the ResearchCommittee at saem@saem.org.

Who are the Principal Investigators in Emergency Medicine?Amy Kaji, MDHarbor - UCLASAEM Research Committee

(continued on page 16)

3

Program Committee Update: 2004 Annual MeetingJudd Hollander, MDUniversity of PennsylvaniaChair, SAEM Program Committee

This year, we had a record number of abstract submissionsfor the Program Committee to evaluate. We also acceptedmore abstracts for presentation than ever before. Overall, 502of 997 abstracts were accepted for presentation.

Each submitted abstract is subject to peer review byapproximately 6 abstract reviewers. Each expert grades eachabstract on 9 individual components that are totaled to give afinal abstract score that ranges from 0 to 20. An averageabstract score is calculated for each abstract.

Because no scoring system is perfect we have severalquality checks within the system. Within each category, wereview the mean scores for each reviewer to make sure thatone category does not contain exceptionally hard or easyreviewers. We review the range of scores within each catego-ry and compare that to the study designs submitted withineach category to reduce biases for or against a particular typeof research. We review a report of all the scores for each indi-vidual abstract to try to make certain that an abstract with asingle low score did not end up with an average below the cut-point. We review a report of all comments sent in by abstractreviewers to look for data splitting or duplicate submissions.These are just a sample of the reports that we review to makethe abstract submission process as valid as possible.

There were a large number of abstracts submitted in eachabstract submission category reflecting the breadth of our spe-cialty.

Over the years, the quality of our science has alsoimproved.The abstract submission process requires each sub-mitter to self report a study design category for their work. Thisyear, abstracts were submitted with the following distribution ofstudy design.

Randomized controlled trial 57Nonrandomized comparison 36Prospective cohort study 115Cross sectional study 47Prospective observational study 168Before and after trial 38Retrospective case control 45Retrospective case series/cohort 193Survey 140Other 95Basic Science 63

Thus more than 40% of the submitted science includedprospective clinical studies.

The meeting will include a litany of great research thatspans the full spectrum of academic emergency medicine,including clinical disease, laboratory investigation and educa-tional initiatives. The outstanding didactic sessions, photogra-phy exhibits, and innovations in medical education exhibitsshould make this meeting another great one.

Category # abstracts submitted

Abdominal/GI/GU 19Administrative 110Airway 45Cardiovascular (non-CPR) 71Clinical Decision Guidelines 40Computer Technologies 15CPR 29Diagnostic Tech/Radiology 61Disease/Injury Prevention 74Education/Prof Development 90EMS/Out-of-Hospital 64Ethics 7Geriatrics 26Infectious Disease 46Ischemia/Reperfusion 16Neurology 31Obstetrics/Gynecology 12Pediatrics 73Psychiatry/Social Issues 31Research Design/Meth/Stats 14Respiratory/ENT Disorders 26Shock/Critical Care 12Toxicology 36Trauma 40

HIPAA Session at the Annual Meeting

Alan E. Jones, MDCarolinas Medical CenterSAEM Research Committee

On April 14, 2003 all parties subject to the Health InsurancePortability and Accountability Act (HIPAA) of 1996 and itsPrivacy Rule were required by the federal government to be incompliance with its standards. The Privacy Rule was issued toprotect the privacy of health information that identifies individ-uals and it affects researchers who require access to or use ofindividual identifiable health related information. This rulechanged the face of clinical research forever. In response to arequest from the SAEM Board of Directors, the SAEMResearch Committee has developed a didactic proposal thatwill be featured at the 2004 Annual Meeting and will focus onboth HIPAA’s effect on clinical research and methodsresearchers can use to cope with the new restrictions andrequirements. This didactic session will be based on theDepartment of Health and Human Services publication“Protecting Personal Health Information in Research:Understanding the HIPAA Privacy Rule.” The session will fea-ture three outstanding and highly qualified speakers, Dr. SueFish, Dr. Carlos Camargo and Dr. Gabor Kelen. The sessionpromises to be informative and give researchers a thoroughunderstanding of the privacy rule and its impact on clinicalresearch. The session will be held on May 18 at 1:30 pm. Wehope to see everyone in Orlando.

4

AEM Consensus ConferenceInformatics and Technology in Emergency

Department Health Care

8:00 am Introduction: Goals and Objectives

8:30 am Keynote Address - "The problemand the promise of informatics andtechnology in Emergency Medicine"

9:30-11:30 am Morning Consensus groups

Each consensus group will attemptto address the same basic questionswith respect to their content domain:

� What literature exists regarding thistopic and the effect on patient care,financial outcomes, efficiency, scala-bility, staff development, and cliniciansatisfaction?

� What studies need to be done to fillknowledge gaps and reach consen-sus?

� What are our best identifiable meas-ures and outcome parameters fortracking progress?

� Based on existing data, do we havea preliminary consensus recommen-dation while awaiting more studies?

1) Where's the beef?The Promise and the Reality of ClinicalDocumentation

2) Data + Algorithms = ActionThe Decision Support andComputerized Physician Order EntryLandscape

3) Disparate Systems, DisparateDataIntegration, Interfaces, and Standards

11:30 am Lunchtime Keynote Address

1:00-3:00 pm Afternoon Consensus groups

1) See One, Do One, Teach OneThe Future of Education andInformatics

2) The Rubber Meets the RoadReal Data, Real Patients, Real TimeTracking and Clinical Results Systems

3) The Computer Is My CopilotReporting, Data Mining, andOperations Management

3:00-4:00 pm Summary Presentation; ConsensusGroups Findings

All SAEM members and others are invited to attend theAEM Consensus Conference. The registration fee is $50and includes lunch. To register, complete the online SAEMAnnual Meeting registration form, which is posted on theSAEM website at www.saem.org.

Call for Papers“Using Information Technology to Improve

ED Patient Care”The use of information technology (IT) in the ED is bound

to increase. Information technology has the potential to quick-ly provide data that can be used to study essential topics relat-ed to the practice of emergency medicine. The questions thatcould be answered with good ED IT are nearly endless, andinclude how to reduce medical errors, assure quality and equalED care, document and monitor ED overcrowding, identifyemerging infectious diseases or bioterrorism, and mend theunraveling safety net. However, there are currently no stan-dards for ED IT. There is no definition of essential componentsof an adequate information system, of universal minimumrequirements for data collection, of common language to allowinformation exchange. Unless the emergency medicine aca-demic community has input into these issues, we will lose thechance to design and implement this powerful clinical tool inthe way best suited to our needs.

The 2004 AEM Consensus Conference will be held May15, 2004 as a pre-day session before the SAEM AnnualMeeting in Orlando. The conference will address the issues ofdeveloping ED IT standards for design, implementation, datarecording, information exchange and IT research; developingan ED IT research agenda; determining how systems issuesand clinical practice patterns need to be considered in devel-oping good ED IT; and determining how ED clinical IT canimpact ED residency training.

AEM has issued a Call for Papers on “Using IT to ImproveED Patient Care.” Original contributions describing relevantresearch or concepts in this topic area will be considered forpublication in the Special Topics issue of AEM, November2004, if received by April 1, 2004. All submissions will be peerreviewed by guest editors with expertise in this area. If youhave questions, contact Michelle Biros at biros001@umn.edu.Watch the SAEM Newsletter and the AEM and SAEM web-sites for more information about the Consensus Conference.

Medical Student Excellence AwardEstablished in 1990, the SAEM Medical Student

Excellence in Emergency Medicine Award is offered annuallyto each medical school in the United States and Canada. It isawarded to the senior medical student at each school (onerecipient per medical school) who best exemplifies the quali-ties of an excellent emergency physician, as manifested byexcellent clinical, interpersonal, and manual skills, and a ded-ication to continued professional development leading to out-standing performance on emergency rotations. The award,presented at graduation, conveys a one-year membership inSAEM, which includes subscriptions to the SAEM monthlyJournal, Academic Emergency Medicine, the SAEMNewsletter and an award certificate.

Announcements describing the program and applicationshave been sent to the Dean's Office at each medical school.Coordinators of emergency medicine student rotations thenselect an appropriate student based on the student's intramu-ral and extramural performance in emergency medicine. Thelist of recipients will be published in the SAEM Newsletter.

Over 100 medical schools currently participate. Pleasecontact the SAEM office if your school is not presently partici-pating.

5

Academic AnnouncementsSAEM members are encouraged to submit Academic Announcements on promotions, research funding, and other items of inter-est to the SAEM membership. Submissions must be sent to saem@saem.org by April 1, 2004 to be included in the May/Juneissue.

Recently the SAEM Board of Directorsconferred emeritus membership on GailAnderson, MD, Richard F. Edlich,MD, PhD and George Podgorny, MD.Each of these individuals have madeoutstanding contributions to academicemergency medicine.

Michael Callaham, MD, has beennamed to a two-year term as VicePresident of the World Association ofMedical Editors (WAME). Dr. Callahamis currently the chair of the WAMEEthics Committee. WAME is the largestorganization of medical science editors,with representation from 620 journals in75 countries.

Donna Carden, MD, has been namedVice Chairman for Faculty Developmentand Research in the Department ofEmergency Medicine at Louisiana StateUniversity Health Sciences Center inShreveport. Dr. Carden is Professor ofEmergency Medicine and Physiology atLouisiana State University.

Glenn C. Hamilton, MD, is a recipientof the Foundation Twenty Medal fromthe Australasian College of EmergencyMedicine. The medal was awarded to

individuals who had significantly con-tributed to the development of theCollege during its formative years 1983-2003. Dr. Hamilton was the inauguralspeaker at the formation of the Collegein 1983, became the first internationalfellow, and has served on the EditorialBoard of Emergency Medicine, theCollege journal.

Debra Houry, MD, MPH, has beenawarded a five-year K23 grant in theamount of $699,900 from the NationalInstitute of Mental Health to study inti-mate partner violence and mentalhealth symptoms. In addition, the NIHhas given Dr. Houry the NIH LoanRepayment award for two years. Dr.Houry is an Assistant Professor in theDepartment of Emergency Medicineand Associate Director of the Center forInjury Control at Emory University.

John B. McCabe, MD, has been namedChair of the Department of EmergencyMedicine at the State University of NewYork Upstate Medical University inSyracuse, NY. Dr. McCabe is Professorof Emergency Medicine.

Edward J. Newton, MD, has been pro-moted to Professor of ClinicalEmergency Medicine at the KeckSchool of Medicine at the University ofSouthern California. Dr. Newton alsoserves as the Interim Chair of theDepartment of Emergency Medicine atLos Angeles County/University ofSouthern California Medical Center.

Jedd Roe, MD, has been named theProgram Director of the EmergencyMedicine Residency Program at theUniversity of Alabama at Birmingham.Dr. Roe is an Associate Professor in theDepartment of Emergency Medicine.

J. Stephan Stapczynski, MD, has beennamed Chair of the Department ofEmergency Medicine at MaricopaMedical Center.

Thomas K. Swoboda, MD, MS, hasbeen appointed Associate Director ofthe newly established EmergencyMedicine Residency Program atLouisiana State University HealthSciences Center in Shreveport. Dr.Swoboda serves as an AssistantProfessor in the Department.

Board of Directors UpdateThe SAEM Board of Directors meets via conference call

every month, as well as face-to-face meetings during theSAEM Annual meeting, the ACEP Scientific Assembly, and theCORD Navigating the Academic Waters and Best Practicesconferences. This article includes the highlights from theDecember 9 and January 13 conference call meetings of theBoard.

The Board reviewed and approved a number of budgetissues including: the budget for the 2004 Annual Meeting; theannual stipend for Dr. Michelle Biros, who begins her secondfive-year term as Editor-in-Chief of Academic EmergencyMedicine; a $20,000 contribution for the dissemination of thefinal report of the Institute of Medicine conference on TheFuture of Emergency Care in the U.S. Health System; a pilotonline Evidence Based Medicine course; the budget and con-tent of the pre-day session at the Annual Meeting on theBusiness Aspects of Health System Management; and the2003 contribution to the employees' pensions.

The Board also approved the year-end Research Fundinvestment report submitted by Steve Dronen, MD. The year-end value of the Research Fund is $2,999,975.

The Board approved a manuscript developed by the EthicsCommittee entitled, “The Ethical Debate on PracticingProcedures on the Newly Dead.” In addition, the Board devel-

oped a position statement on performing invasive proceduresfor teaching purposes on recently deceased patients, which ispublished in this issue of the Newsletter. The manuscript andposition statement will be submitted to Academic EmergencyMedicine for consideration of publication.

The Board reviewed the first draft of a manuscript devel-oped by the National Affairs Committee entitled, "Financing ofEmergency Medicine Graduate Medical Educational Programsin the Era of Declining Medicare Reimbursement/Support."

The Board approved the Grants Committee recommenda-tions regarding the 2004-05 grant recipients. Information onthe grant recipients will be published in the May/June issue ofthe Newsletter.

The Board approved a slate of nominees for the open posi-tions on the American Board of Emergency Medicine. In addi-tion, the Board submitted a list of academic emergency to theNational Center for Injury Prevention and Control (NCIPC) atthe Centers for Disease Control and Prevention (CDC).

The Board named Dr. Judd Hollander to serve as the rep-resentative to the Biochemical Markers in Patients with AcuteCoronary Syndromes and Heart Failure project. The Boardunanimously approved emeritus membership status for GailAnderson, MD, Richard Edlich, MD, and George Podgorny,MD.

6

Ethics Corner: Are We Teaching Our Residents the Ethics of Private Practice?Jason A. Hughes, MDTexas Tech UniversitySAEM Ethics Committee

In a recent on-line article in the American MedicalAssociation newspaper, it was noted that people who are“squeaky wheels” need some extra care and attention. In thesame article, it was also noted that we should cater to thembecause they are usually paying patients and thus they pay thebills, so to speak.

This issue is an important one, as many residency pro-grams are situated in areas where patients are either povertystricken, or having difficulty making ends meet. Institutionssuch as these are excellent training grounds as they give usthe ability to care for people who are usually in desperateneed, and we are rarely put in a situation where “squeakywheels” try to make their presence known.

We have seen some patients in our own hospital feignchest pain in order to obtain prescription refills that are “free”.Others have been brought in screaming at the top of theirlungs due to abdominal pain. We, as teachers and role mod-els, hopefully show the residents that after a careful examina-tion and treatment plan, there should be an inventory of thequiet patients in the emergency department who could easilyhave life threatening conditions.

However, it seems rare that people who are fairly well to dopresent to our county hospital, which is located five minutesfrom the US-Mexican border. In the private institutions acrossour country, it is suspected that we have a different problem.The question is how to resolve this in a quiet, ethical manner.

In many private institutions we have seen patient familiesinsist on “the best care” for their relatives; they will sometimesgo through a checklist and let the emergency physician knowwhat plan of action needs to be taken. At times, families seemto be more aggressive concerning their care, and they seem tobe lacking in the understanding of triage in spite of carefulexplanations.

For an emergency department with single physician cover-age, catering to the whims of the family can eat away precioustime. Others in the ED could have conditions requiring your

immediate attention. However, not catering to certain whimsmight lead to concern over reprimands from administration aswell as letters of complaint.

The overall question could easily be summarized as fol-lows: “If the CEO of your particular hospital limps into your EDwith an ingrown toenail, should this take precedence overother patients?”

As a teacher of medicine, it would seem that this is a clear-cut answer…until we are placed in that very situation.

In our teaching, it would seem appropriate to discuss theprivate practice world didactically and practically. Althoughmost programs do not condone a large amount of moonlight-ing, a degree of moonlighting may be appropriate if carefullymonitored. There should be a free discussion about suchissues as this that seem more likely to occur in a private set-ting.

What is the answer to the “squeaky wheel” problem? Itseems to be institution dependent, but it is important to havethe backing of the ED director. Waxing philosophical to apatient and family about their inappropriate “squeakiness” isyet another waste of time and could lead to an argument.Calling their physician at home may assist you tremendouslyas these patients are often well known. These are only a fewsuggestions. The main one is to help our residents understandthese types of dilemmas so they may develop their own planof attack. Otherwise, the resident may have unmet expecta-tions upon arrival to their first “job” situation.

One patient decided to squeak a little bit too loudly in ourED waiting room. He thought that he could jump ahead ofother patients by calling 911…from the waiting room. Myunderstanding is that EMS was “on the scene” in just a fewseconds. They strapped him to a gurney and brought himthrough triage. After a thorough evaluation he was sent backout to the waiting room.

Sometimes, the circle is left unbroken.

Position Statement: Performing Invasive Procedures for Teaching Purposeson Newly Deceased Patients

The following position statement was approved by the Board of Directors in January 2004.

Position: SAEM believes that per-mission should be obtained from thefamily or next of kin prior to performinginvasive procedures for teaching pur-poses on newly deceased patients inthe emergency department.

Background: Emergency medicinetraining programs have an obligation toensure trainees' procedural and techni-cal skills, including abilities to performinvasive procedures. Historically, manytraining programs have taught invasiveprocedures on recently deceasedpatients because of the realism, high

quality, and accessibility.A fundamental requirement of the

profession of emergency medicine is tomaintain public and individual trust.Therefore SAEM believes that permis-sion should be obtained from the familyor next of kin prior to teaching invasiveprocedures on newly deceased patientsin the emergency department.

It is recognized that the recommen-dation to obtain permission may limitteaching opportunities on the recentlydeceased due to physician discomfortasking for permission, family unwilling-

ness to grant permission, family inac-cessibility, and acute grief that impairsthe discussion. It is acknowledged thatother teaching sources such as cadav-ers, simulators, and animal laboratoriesare frequently employed for teachinginvasive procedures but are less acces-sible, less realistic, and very costly.Despite these acknowledged chal-lenges, it is believed that competentemergency physicians can be trainedwithin the constraints of the SAEM posi-tion to obtain permission.

7

Call for Authors and EditorsCORD/SAEM Diversity Task ForceCultural Competency Curriculum

The CORD/SAEM Diversity Taskforce was organized in2003 by CORD and SAEM. The objectives are to develop acurriculum to incorporate diversity awareness, cultural com-petency knowledge and skills for residency training programsand create a website product.The charge to the task force (TF)is to develop a module for EM programs to use to heightenawareness of diverse cultural issues and provide training ofhealth care providers regarding these issues. The TF is devel-oping a "Cultural Competency Curriculum" as an educationalresource and a Diversity website has been created for the TFto deposit training materials. Elements of the curriculuminclude patient/physician, physician/physician, and faculty/res-ident interaction. The TF is working on a three-tiered approachin developing the curriculum. Tier one content includes edu-cational chapters written or to be written by the CORD andSAEM membership on topics such as interpreter services,physician/patient interaction, LGBT population/physician -patient relations, spirituality differences in diverse populations,educating residents to care for multi-cultural patient popula-tions, and culturally competent health care promotions toname a few subjects. Tier two content contains chapters onethnic/racial groups, which includes comments about beliefs,customs and traditions of each ethnic/racial group and a liter-ature review regarding group-specific health risks and out-comes. Tier three content includes cultural competency teach-ing cases. Teaching cases contain case presentations specif-ic to a cultural subgroup with instructor versions (questions for

discussions and teaching content regarding attitudes/assump-tions for the physician and patients or relatives and knowledgeof health beliefs and customs inclusive of knowledge ofprovider and of community where applicable. Also included inthe teaching cases are aspects of cross-cultural tools andskills including case outcome and disposition. For each of thetier one, two and three sections references are included.

The TF has developed sample chapters and teachingcases which are available for members to use when develop-ing chapters and cases. The Task Force extends an invitationto the CORD and SAEM memberships to develop chaptersand teaching cases. The TF currently includes Antoine Kazziand Marcus Martin as co-chairs and Sheryl Heron, LynneRichardson, Kumar Alagappan and Ishmael Griffin. Supportof the task force is provided by Glenn Hamilton (SAEM Boardliaison) and Scott Rudkin (website UCIHS). Yvonne Chan,MD, and Robert Kwon, both of UMDNJ have made major con-tributions to the developmental efforts.

If you're interested in developing a chapter, please contactMarcus Martin at mlm8n@virginia.edu. If you're interested indeveloping a chapter on a specific ethnic or racial subgroup,please contact Antoine Kazzi at akazzi@uci.edu. If you'reinterested in developing a teaching case, please contactSheryl Heron at sheron@sph.emory.edu. If you're interestedin being an editor for the curriculum material, please contactLynne Richardson at lynne.richardson@mssn.edu.

Southeastern RegionalSAEM MeetingMarch 19-20, 2004

Chapel Hill, NC

The 2004 Southeastern Regional SAEM Meeting willbe held in Chapel Hill, North Carolina on March 19-20, 2004.

There will be oral and poster research presentations,round table discussions with leaders in academicEmergency Medicine, keynote presentations bynationally recognized emergency physicians, andtime to socialize with colleagues in the southeast.

Registration: medical students and residents are par-ticularly encouraged to attend, and receive a dis-counted registration fee of $50 (medical students)and $75 (residents or nurses). Registration for attend-ing physicians is $125. For assistance with registra-tion and hotel accommodation, contact: Julie Vissers• phone: (866) 924-7929 or (919) 932-6761 • fax:(404) 795-0711 • email jvissers@nc.rr.com. You mustreserve your room by February 18, 2004 to get theconference rate for accommodations.

8th Annual New England Regional SAEM Meeting

April 28, 2004Shrewsbury, Massachusetts

Keynote Speaker: Jeffrey Kline, MD

The meeting will take place April 28, 2004, 8:00 a.m.- 4:00 p.m. at the Hoagland-Pincus ConferenceCenter in Shrewsbury, MA; www.umassmed.edu/conferencecenter/

Please send registration forms to: Gail Kolodziej,Staff Assistant, Department of EmergencyMedicine; Porter 5979, Baystate Medical Center,759 Chestnut Street, Springfield, MA 01199. Emailcontact is Gail.Kolodziej@bhs.org

Registration Fees: Faculty = $100; Residents/Nurses = $50; EMTs/Students = $25. Late fee afterApril 9, 2004 = add $25. Make checks payable toBaystate Medical Center Emergency Dept.

SAEM/ACMT Michael P. Spadafora Medical Toxicology ScholarshipDr. Michael P. Spadafora was an academic emergency physician and medical toxicologist who was a member of

SAEM and the American College of Medical Toxicology (ACMT) and was dedicated to resident education. After hisdeath in October 1999, donations were directed to SAEM for the establishment of a scholarship fund to encourageEmergency Medicine residents to pursue Medical Toxicology fellowship training. ACMT has graciously agreed todonate matching funds.

Two recipients will be chosen to attend the North American Congress of Clinical Toxicology (NACCT), which willbe held September 9-14, 2004 in Seattle. Each award of $1250 will provide funds for travel, meeting registration,meals, and lodging. Any PGY-1 or 2 (or PGY-3 in a 4 year program) in an RRC-EM or AOA approved residency pro-gram is eligible for the award. The deadline for application is May 1, 2004. Scholarship recipients will be announcedat the annual SAEM and NACCT meetings. Each recipient will also be required to submit a summary of the meetingfor publication in the SAEM Newsletter and the ACMT Newsletter. The articles of the inaugural recipients of theScholarship, Dr. Lindgren and Dr. Ferguson are published in this issue of the Newsletter.

Applications must be submitted electronically to saem@saem.org and include:1. Curriculum Vitae of applicant2. Verification of employment and letter of support from the applicant’s program director3. Letter of nomination from an active member of SAEM and/or ACMT4. 1-2 page essay describing the applicant’s interest and background in Medical Toxicology

How Moonshine Took Me to ChicagoJeffrey D. Ferguson, MDUniversity of Virginia2003 Spadafora Scholarship Recipient

The 2003 North American Congressof Clinical Toxicology was held inChicago in September. I was able toattend the meeting thanks to theMichael P. Spadafora MedicalToxicology Scholarship. This was thefirst year the scholarship, a collaborationof the Society of Academic EmergencyMedicine and the American College ofMedical Toxicology (ACMT), was award-ed.

The CPC competition set the tone ofthe conference, as cases involvingunknown poisons were presented withinterjections from clinical toxicologists.They dissected each case, forming adifferential diagnosis and paring downtheir opinions based on the revealedinformation. I was familiar with this for-mat from previous CPC conferences,but was amazed by the clinical acumenof the presenters as they outlined theirapproach to the case, then teased outcritical information to decide on the rightdiagnosis and management. Along withbeing educational, the presenters did anexcellent job at making their presenta-

tions colorful and humorous, drawing aroom-filling crowd.

The following four days were filledwith lectures and workshops from theleading organizations of clinical toxicolo-gy and poison control centers fromNorth America and Europe. These talkspresented the most recent data of theprofession covering consensus viewsregarding treatment and managementguidelines, toxins that present newoccupational dangers, and lessonslearned from disasters and eventsincluding use of chemical warfare. Mypersonal favorite was the presentationby the Toxicology Historical Societyabout the infamous moonshiner, FatHardy, who was responsible for a largenumber of methanol poisonings. Thisbrought the conference full circle for me,since much of the reason I was selectedfor the Spadafora scholarship was myown research into contaminated moon-shine.

Over two hundred abstracts werepresented during the conference. Alongwith original clinical and bench

research, they included fascinating casepresentations and poison control centerdata. I especially enjoyed the opportu-nity to talk with presenters to gain differ-ent perspectives and ideas regardingtheir research topics.

While in Chicago, Leslie Dye, thewife of the late Michael Spadafora, host-ed this year’s two scholarship winnersfor lunch. This allowed me to learn moreabout the physician behind this name-sake award. Through his work in emer-gency medicine, toxicology, and medicaleducation Dr. Spadafora touched thelives of countless patients and physi-cians. I am certain his legacy will con-tinue to influence the paths of risingphysicians for years to come.

Finally, I would like to express mysincerest gratitude to SAEM and ACMTfor this scholarship and the opportunityto attend the NACCT. I thoroughlyenjoyed my time in Chicago and lookforward to continuing my efforts in thefields of emergency medicine and toxi-cology.

8

9

Summary of the Research Symposium at the 2003 North American Congress of Clinical Toxicology

Kjell Lindgren MD, MSHennepin County Medical Center2003 Spadafora Scholarship Recipient

Chicago has been busy this fall. Heartbroken hosts to base-ball’s upstart and eventual World Champion Florida Marlins,the “Second City” also hosted the 2003 North AmericanCongress of Clinical Toxicology’s annual meeting. And whilethis important annual gathering lacked the bombast of SammySosa’s bat, the mystique of a caprine curse, or even nationaltelevision coverage, the NACCT fielded a terrific line-up ofresearch presentations for its own “fall classic”.

Two hundred and sixty five abstracts were selected for posterand platform presentations, covering all realms of clinical toxi-cology. With such a large meeting and so many abstracts, onecannot hope to summarize all of the important research beingaccomplished. As such, this article will simply touch on a fewpresentations that were especially interesting or clinically per-tinent.

The New Coke… Body-stuffers are individuals who sponta-neously swallow (often poorly wrapped) cocaine in an attemptto hide evidence, with the unguarded optimism that everythingwill come out OK in the end. While the literature does notdefine a set observation period for the acute presentation ofthese patients, many clinical centers will watch the asympto-matic patient for 6 hours before discharging them to their owncare. Yao et al. provided an account of a 26 year old male whopresented 90 minutes after ingesting 5-8 packets of rockcocaine. The patient presented with normal vital signs, wastreated with activated charcoal and polyethylene glycol, andremained well until 7.5 hours post-ingestion when he becamesymptomatic with hypertension, tachycardia, and seizures.This case suggests that 8 to 10 hours may be more appropri-ate, that further research into this issue is needed, and thataluminum foil does not have a waterproof seal.

To check or not to check… Patients presenting to the EDwith overdose in the setting of a suicide attempt will often haveboth a serum salicylate and acetaminophen level checked.While salicylate levels are easily obtained, there is still somecontroversy as to the appropriate use of the test. Wood et al.performed an observational retrospective review of 726 patientcharts and lab records. They found that a positive history ofsalicylate ingestion was 81% sensitive, with a positive predic-tive value of 79%. More importantly, a negative history of sal-icylate ingestion had a negative predictive value of 98%. Whilethis study had some important limitations (retrospective, selec-tion bias, and small n with possible type II error), it does helpaffirm the practice of those who believe that a salicylate levelis unnecessary in the conscious, asymptomatic overdosepatient who denies ASA ingestion.

And now for something completelydifferent…Escitalopram (Lexapro), an enantiomer of theracemic SSRI citalopram (Celexa), was introduced to the USmarket about a year ago. Because of its novelty, little wasknown about this drug’s side effects and activity in overdose.Wiegand et al. presented a case of serotonin syndrome in a75-year-old male who had just started SSRI monotherapy fordepression. The patient presented with one day of alteredmental status, fever, and new onset upper extremity tremor.The patient had been taking escitalopram 10mg PO for twodays, had never used an SSRI before, and was taking no other

serotonergic medications. While the patient’s urine showedcitalopram, the remainder of lab tests and imaging were unre-markable. Escitalopram was discontinued on admission andthe patient was asymptomatic by day 3. This case shouldremind us to keep serotonin syndrome in our differential diag-nosis – even in the setting of SSRI monotherapy at therapeu-tic doses.

What’s good for the goose, is good for the gosling…Sulfonylurea overdose can result in resistant hypoglycemiafrom the stimulation of pancreatic b-cells and subsequentinsulin release. Management of sulfonylurea overdose typical-ly involves 10% dextrose IV infusion, frequent blood glucosechecks, and 50% dextrose IV boluses as needed. Reboundhypoglycemia from dextrose infusion may require octreotide tosuppress insulin release from b-cells. Kent et al. reported acase in which octreotide was used in managing resistant hypo-glycemia in a 16 month old child. Despite IV dextrose infusionand several boluses of 50% dextrose, the patient continued tohave rebound hypoglycemia. Octreotide 10mg IV over 15 min-utes was used twice over the course of the patient’s treatmentwith good effect. The patient was discharged home 24 hourspost ingestion with no sequelae. This case serves to remindus that octreotide may be an effective therapy for sulfonylureaoverdose in both adult and pediatric patients.

Make like glue and stick around… Buproprion is an atypicalantidepressant with norepinephrine, serotonin, and dopamineactivity used in smoking cessation and depression. Seizureshave been seen in overdose with both the immediate and sus-tained release forms. Many clinical centers will observe thesepatients for 12 hours prior to disposition. Goldstein et al. pre-sented a case series that identified four patients that haddelayed onset of seizures. Two patients had their initial seizureafter 12 hours of observation. One patient’s first seizureoccurred between 12 and 18 hours, the second patient’s initialseizure occurred at about 38 hours. This study suggests thatthe current practice of charcoal and 12 hours of observationmay be inadequate.

I thought you said your dog did not bite! That is not mydog…Quetiapine (Seroquel) is an atypical antipsychotic withdopamine and serotonin activity that is structurally similar tothe tricyclic class of antidepressants. Caravati et al. conduct-ed in vitro evaluation of quetiapine’s potential to cross reactwith TCA immunoassays. They found significant cross-reac-tivity with both the quantitative and two qualitative assays test-ed. This study should remind us of the fallibility of our lab testsand that our clinical suspicions should direct lab investigationand not the other way around.

In conclusion. For those of you who were unable to attend themeeting in Chicago, I hope this article provides some sense ofthe interesting topics that were presented. The symposiumprovided an important outlet for cutting edge research andpractical presentations and I hope you will consider attendingthis meeting in the future.

Finally, I would like to thank the American College of MedicalToxicology, the Society for Academic Emergency Medicine,and Dr. Leslie Dye for the opportunity to attend this meeting.

10

Academic Emergency Medicine and the “Tragedy of the Commons”Roger J. Lewis, MD, PhDHarbor-UCLA Medical CenterSAEM Past President

This manuscript is based on the 2003 President’s Address delivered by Dr. Lewis at the 2003 SAEM Annual Meeting in Boston,Massachusetts.

The “Tragedy of the Commons”Defined

Occasionally, one comes across anidea which, although old, can lead togreater insight into current problems.The concept of the “Tragedy of theCommons” is such an idea. To definethe Tragedy of the Commons, one canbegin by examining each word. Theterm “tragedy,” according to the seconddefinition in Webster’s 7th NewCollegiate Dictionary, is “a seriousdrama typically describing a conflictbetween the protagonist and a superiorforce (as destiny) and having a sorrow-ful or disastrous conclusion…”. Theword “tragedy,” when used to describe astory or legend, is not meant to implyonly a sequence of unfortunate orpainful events but, furthermore, to implya certain natural progression orinevitableness of those events.

Also according to Webster’s, the fifthdefinition of a “common” is “a piece ofland subject to common use: as a: un-divided land used especially for pasture(or) b: a public open area in a munici-pality…”. In old England, the term “com-mons” referred to an area of land whichwas used for grazing livestock. It was ashared common resource used for thebenefit of all. In contrast, however, eachshepherd owned their own livestock,and benefited only from the livestockwithin their herd. In modern times, theterm “commons” also applies to anyarea of public use which is open to all.

The Tragedy of the Commons wasfirst described by William Forester Lloydin 1833, but placed into modern contextby population biologist Garrett Hardin, inan essay published in 1968 in the jour-nal Science1 and updated in 1998.2 TheTragedy of the Commons is a principlethat applies in numerous healthcare,academic, and other settings. It is oneof those rare concepts that, once under-stood, is found to be relevant in moreand more areas of our daily lives. 3-6

In its original context, the Tragedy ofthe Commons refers to the fate ofshared pasture land. The old Englishsystem of sharing pasture space seemsinherently fair, and our intuition might bethat this system would maximize the

benefit of the common space for all.There is appealing equality and simplic-ity in the commons. Each shepherdfinds himself in the same position—noone owns the land or has more or lessclaim to it.

Every year, each herdsmen seeks toimprove his wealth by deciding whetherto graze additional, fewer, or the samenumber of animals. Of course the com-mons has a fixed “carrying capacity”and, as the number of animals grazedon it increases and approaches thislimit, the average weight gain of eachanimal decreases. From the point ofview of each herdsman, the decision toadd one more animal to his herd yieldsalmost the benefit of one of his currentanimals. It is true that each animal maybe slightly leaner because of the addi-tional competition, but virtually all of thebenefit of one animal will be realized.The benefits of adding an animal is nei-ther shared with others nor diluted. Incontrast, the negative effect on the com-mons is distributed among all herds andall herders, and is thus relatively smallfrom the point of view of each individualherder. Thus, any rational herder willconclude that it is in their best interest toadd additional animals to their herdeach year.

The tragedy occurs because eachherder finds himself in exactly the samesituation, and thus each herder addsmore and more animals to his herd.Eventually the commons is overgrazed,and all of the animals become weak,underweight, and are susceptible to dis-ease. This leads to the collapse of theherds and the downfall of the herders. Afundamental asymmetry—completeinterest in the size of one’s own herd,but only an indirect and partial interestin the well-being of the commons itself,leads to this tragedy. This sequence ofevents, which results in the destructionof not only the commons, but also of theherds and the herders, is an inevitableresult of the system that governs theuse of the commons—hence thetragedy.

What are the key elements of thetragedy of the commons? First is theexistence of a shared but limited

resource, vitally important to the life ofthose who share it. Second is the desireof each participant to have more of theresource than currently allocated tothem. Finally, there is equal and unfet-tered access—a lack of external control.For example, there is no governingagency which sets limits on the numberof sheep each herder may graze on thecommons. The outcome of this combi-nation of factors is sometimes summa-rized as “freedom in a commons bringsruin to all.” Importantly, these elementsoccur frequently in many settings,sometimes even intentionally, recreatingthe tragedy. The three elements of thetragedy, when in place, lead rationalpeople to make decisions that ultimate-ly destroy their common resource.

Have we learned the lessons taughtby the tragedy of the commons?Consider the fact that cattlemen in theUnited States still constantly pressureauthorities to allow larger herds to grazeon federal land. Or the fact that manyfishermen still believe in the “freedom ofthe seas” and the “inexhaustibleresources of the oceans.” While wemight criticize these groups for failing toheed lessons of the past, we also mustconsider the current state of emergencyhealthcare and the current state of aca-demic emergency medicine. In the restof this commentary, I would like to pointout some situations which partially orcompletely replicate the tragedy of thecommons, but from within the world ofemergency medicine.

Emergency Medical Care as aCommons

The emergency medical services(EMS) system is a resource that, by law,is available to all without restriction. It isalso a limited resource, as both equip-ment and personnel are limited bybudgetary constraints and competingpriorities of local, county, and state gov-ernments. Furthermore, there is gener-ally no negative incentive in place tolimit use of the EMS system for non-emergency care. Since each of the keyelements of the Tragedy of theCommons are recreated in our EMSsystem, it is not surprising that we see

(continued on next page)

11

an EMS system that is often stretchedto capacity, used as an expensive taxiservice, or that there is a subset ofusers who utilize the system far morethan others.

Just as with the overgrazing of pas-ture lands, this dynamic leads to adegradation in the quality of the com-mon resource. This degradation is man-ifested as reduced availability of EMSunits, long response times, provider“burnout,” and the institution of compen-satory changes (e.g., tiered response).Each of these factors reduces the over-all quality of the resource—a deteriora-tion of the commons.

The emergency care provided inemergency departments across thecountry is also an example of a com-mons. It is a resource which is valuableto all, especially in times of unexpectedneed, and under EMTALA/COBRA leg-islation it is available to all withoutrestriction or consideration of ability topay. 7 For many members of our socie-ty the emergency department (ED) istheir only access to needed medicalcare, and they often need more carethan they currently receive. In addition,there are little or no incentives to limituse. The resulting behavior, on the partof a subset of users, is to use the ED astheir primary source of care, to use theED for non-emergency care, and to failto identify and access other sources ofprimary care that they may have avail-able to them. It is important to note thatthese behaviors are the logical andinevitable consequence of creating acommons—they are not the result ofany lack of moral character or judgmenton the part of individuals. In fact, theseindividuals are appropriately reacting tothe healthcare system we have created,in which there is only one source ofmedical care that is open to all withoutrestriction or limit. The irony here, ofcourse, is that primary care in our coun-try is a closely managed resource,whereas emergency care is purposelyunmanaged.

As is well known to all emergencyphysicians, our emergency departmentsare being “overgrazed.” This is mani-fested by overcrowded waiting roomsand EDs, frustration on the part of bothphysician and nurse providers, physi-cian “burnout,” and decreased qualityand timeliness of care. It is fundamen-tally irrational for academic emergencyphysicians to bear witness to the contin-ual degradation of the commons that is

emergency healthcare while, simultane-ously, arguing vehemently that this pre-cious resource remain unmanaged.Unfortunately, that is exactly the positionof many organizations and leaders with-in the field of emergency medicine.

Now consider the moral andequity arguments in support of universalhealth insurance in our country. Thetotal public funds to be spent on health-care is essentially limited by externaleconomic and political factors, creatinga sort of economic commons. Under ourcurrent system, of course, many mem-bers of our society have essentially noaccess to health insurance. This consti-tutes de facto management of the com-mon resource. Ironically, arguments infavor of universal health insurance, tothe extent that they fail to increase thesize of the commons by creating newsources of funding, are arguments infavor of creating the key elements of thetragedy. Given the limited resources,this tragedy would consist of universalhealth coverage which, over time, isslowly degraded in its scope and value,and in its ability to ensure quality health-care for all. The initial stages in thisprocess have already been seen insome settings, in which a large segmentof the population is “covered” using pub-lic funds, but the level of reimbursementis so low that skilled providers will notvoluntarily provide care. With thisapproach, we may create an illusion ofuniversal healthcare, but that may be all.

Research Development and Trainingin Academic Emergency Medicine

I will now switch my focus from emer-gency healthcare to the processesrequired to establish a productiveresearch program in an academic emer-gency department. I will begin by dis-cussing a cycle of research productivity,and then identify relevant commons andconsider how we manage thoseresources.

In the figure, different stages in thedevelopment of a research program,and their relationships, are shown. Afundamental first step is the researchtraining of one or more (hopefully more)core investigators. Without suchresearch training, it is unlikely that aninvestigator can initiate, obtain fundingfor, and complete research projects ofthe quality and scope necessary to gar-ner recognition for the department as awhole. Solid research training leads toboth an improved quality and increased

quantity of research in a department,which in turn leads to local recognitionfor the department, usually from insidethe medical school or university. Suchinternal recognition leads to improvedopportunities for local funding and foracademic recognition. With the addi-tional resources available from localfunding and improved opportunities forcollaboration associated with recogni-tion locally, investigators in the depart-ment are able to initiate and completeprojects of a quality and scope that yieldrecognition nationally. National recogni-tion leads to opportunities for extramuralfunding, as well as for substantive col-laboration outside of one’s own institu-tion. These opportunities, in turn, ulti-mately yield other research resourcesand infrastructure through extramuralgrants and/or national collaborations.

The last link in the cycle, and per-haps the most important, is the relation-ship between a nationally-recognizedresearch program and the opportunityto provide research training. This linkoccurs both because of the relativeease with which appropriate candidatescan be recruited if one has a nationalreputation, as well as the increasedchance of obtaining extramural fundingfor career development and traininggrants when the local mentors havedemonstrated productivity. Thus, therecan be a complete, self perpetuatingcycle of research productivity and devel-opment, but it must begin with a coregroup of well-trained investigators.

The table shows key elements whichare required by a trainee to acquireessential research skills—the first stepin development of a research program.In the following I will focus on two ofthese key elements: (1) the availabilityof a qualified and effective mentor; and(2) sufficient protected time to develop aset of research skills.

Although specific data are difficult toobtain, it is widely believed that a goodmentor is one of the most importantpredictors of long-term research suc-cess on the part of the trainee. This isespecially true for trainees with little for-mal research training, as is typical ofyoung investigators in emergency medi-cine whose primary post-college train-ing is focused on medicine (e.g., an MDdegree and residency) rather than onresearch activities. Accordingly, thequalifications of the mentor, the men-tor’s track record in research training,and the quality of the mentor-trainee

“Tragedy of the Commons” (Continued)

(continued on next page)

12

relationship are all important factorsconsidered during the evaluation of fel-lowship and research training grantapplications.

From the point of view of a youngresearcher, the mentor is a type of com-mons. A good mentor is extremely valu-able to all trainees wishing to enhancetheir research skills and productivity.The mentor is valuable unless, ofcourse, they must be shared with toomany other trainees or have too manyother research, clinical, or administra-tive responsibilities. If the mentor isspread too “thin,” regardless of theirqualifications and intent, they will be oflittle use to their trainees. One way thisissue can be addressed, however, is toincrease the “size” of the mentor-com-mons, by recognizing that good mentorscan often be found outside of emer-gency medicine. At institutions in whichinsufficient mentoring capacity is avail-able within emergency medicine, onemust be willing to identify and cultivaterelationships with outside mentors.

Given that mentors are a valuableand limited resource, it is ironic that wesometimes create a “tragedy” by insist-ing that all emergency medicine resi-dents perform research. This practiceoften leads to the mentor’s time beingspread so thin that they are of little useto the few residents who truly wish topursue a research career, or to the jun-ior faculty within their department whodesperately need their assistance. Inessence, we recreate the Tragedy of theCommons and this is manifested by adegradation in the quality of mentoringfor all who need it.

In virtually all departments of emer-gency medicine, non-clinical, non-administrative time is also a type ofcommons. Such protected time is criti-cally important to the young investigatorwishing to develop research skills and toestablish a track record of productivity.In fact, such protected time is critical foreven the most experienced investigatorswho wish to remain productive. If thenon-clinical, non-administrative time isspread evenly among all faculty, howev-er, in most settings the absolute quanti-ty of such time will be so limited that itwill be insufficient to support the career-development phase of a young investi-gator. In other words, even with the cur-rent size of our “herds” of faculty mem-bers (which are necessary to fulfill ourclinical and clinical teaching responsibil-ities) the commons of protected time is

insufficient to support the developmentof a research career if distributed equal-ly.

As a field, how good are we atresearch training and research careerdevelopment? In 1999, Blanda et alpublished a study based on a survey ofself-identified research directors inemergency medicine.8 That surveyshowed that 53% of research directorswere junior faculty (at the instructor orassistant professor level), and that themedian length of time spent in the posi-tion was three years. Furthermore,approximately one-third of researchdirectors reported no publications in theprior three years. Only 27% of researchdirectors had a research degree and21% had completed a research fellow-ship, although the duration of theseresearch fellowships was unclear. 8Assuming that the research director isusually the research mentor in eachdepartment, it would appear that, as aspecialty, we have been largely unsuc-cessful in creating an adequate group ofmentors (the commons) for our youngtrainees.

It is instructive to contrast theresearch training and productivity ofresearch directors in emergency medi-cine with the minimum training require-ments for trainees suggested in theguidelines for institutional fellowshipgrants supported by the NationalResearch Service Awards (NRSA) pro-gram. In the latter case it is stated that“…postdoctoral trainees should agree toengage in at least 2 years of research,research training, or comparable activi-ties beginning at the time of appoint-ment since the duration of training hasbeen shown to be strongly correlatedwith post-training research activity.”9 Inother words, the national standard,based on actual data regarding subse-quent research success, implies a high-er level of training for fellows than weare able to document for the majority ofresearch directors in emergency medi-cine. Thus, for most departments to beable to initiate the cycle of researchtraining and development shown in thefigure, a substantial and sustainedinvestment in our research trainees inthe form of protected time andresources, must be made.

Avoiding the Tragedy of theCommons

How do we avoid the tragedy of thecommons and maximize the benefit of a

common resource for all? Mostapproaches attempt to alter one of thekey elements of the tragedy so that theunderlying dynamic is never realized.Approaches include converting com-mon resources to private property, elim-inating the commons altogether, or reg-ulation of the use or active allocation ofcommon resources—restricting person-al freedom. Such approaches can besummarized as “mutual coercion, mutu-ally agreed upon.” In addition, a numberof authors have identified other socialmechanisms that, in specific cases,appear to prevent the tragedy.

While mutually agreed upon limita-tions may prevent destruction of thecommons, in some cases the resourceswill be so dilute as to be of little use(e.g., protected time). Thus, the maxi-mum benefit for the whole group, or anentire academic department, may beachieved only with unequal allocation ofa scarce resource. This is unsettling tomany who implicitly assume that anequal allocation of resources is optimal.

There are a number of common bar-riers to any solution to the Tragedy ofthe Commons. These barriers includedevotion to individual freedoms, namely,a belief that all should have equal andunfettered access to any valuableresource. In many settings, we seem tobelieve that equality requires freedom—that external controls are inherentlyunfair. In many settings there is also adistrust of external regulation.Furthermore, many believe in simplisticdefenses of the right to equal access tocommons. By simplistic, I mean withoutregard to an analysis of the effect of thisfree and unfettered access on the com-mons itself. Lastly, many believe in thefundamental value of equality, inde-pendent of the consequences of suchequality. A defense of right to access,however, without explicit considerationof the consequences, is shortsightedand often misleading.

What solutions have been found tothe tragedy? Solutions include limits onfishing in international waters, the use ofparking meters, and international limitson air pollution. Examples in the health-care setting are more difficult to find,although systems for the equitable dis-tribution of solid organs for transplanta-tion is one example.

Focusing back on the field of emer-gency medicine, what are possible solu-tions to the tragedies that we have cre-ated? One approach to avoiding the

“Tragedy of the Commons” (Continued)

(continued on page 20)

13

Solicitation of Readings for ABEM Future Lifelong Learning and Self-Assessment Test

A cornerstone of ABEM’s new EMCC program is the con-cept of Lifelong Learning and Self-Assessment (LLSA). Theprimary goal of LLSA is to promote continuous learning on thepart of ABEM diplomates. ABEM will facilitate this learningwithin the context of LLSA by identifying an annual set of read-ings to guide diplomates in self-study of recent EmergencyMedicine (EM) literature.

ABEM has sought to involve the EM community-at-large inthe LLSA process by inviting EM organizations and ABEMdiplomates to make suggestions for readings to the ABEMBoard of Directors. For the 2005 LLSA to be developed nextyear the Board received over 125 suggestions collectively fromACEP, SAEM, CORD, AAEM, and a number of individualABEM diplomates.

Submission Criteria for LLSA ReadingsThe Board has determined that readings used for the LLSAtests should meet the following criteria:1. Focus on recent advances or current clinical knowledge in

Emergency Medicine;2. Be clinically oriented in content;3. Be drawn from peer-reviewed EM journals, peer-reviewed

journals from related primary specialty fields, textbookchapters, or updated practice guidelines;

4. Be published in printed or electronic form within the imme-diate five years preceding the LLSA test in which it will beused;

5. Relate to either the designated content areas for a givenyear (50%), or to the remaining content areas (50%) of theEM Model “Listing of Conditions.”

Content of LLSA Test in 2006Although readings for the first LLSA test in 2004 have

already been selected, the Board welcomes reference sug-gestions for future LLSA tests from the larger EM communityon an ongoing basis.

Currently, ABEM is soliciting readings for the 2005 LLSAtest, for which the designated content areas will be Traumatic

Disorders and Cutaneous Disorders. ABEM will select 50%of the readings for the 2005 LLSA test from these two desig-nated areas, while the remaining 50% of test content will bedrawn from the remaining content areas of the EM Model“Listing of Conditions.”

How to Submit Recommendations for LLSA ReadingsFor each reference submitted, ABEM must receive the fol-

lowing two items:

1. Complete an LLSA Form for each reference that you rec-ommend to the Board. Be sure to provide all requestedinformation for each reference, including the article titlecompletely written out, the journal name, etc. Do not useabbreviations. Do not alter the form in any way, except toadd the requested information in the space provided. TheLLSA Reference Form is available from ABEM and mayalso be downloaded as an MS Word document from theABEM website. The form can be computer-printed or type-written.

2. Provide one paper copy of the article, chapter or other textfor which you have submitted a reference must be mailedor faxed to ABEM in order to be considered for inclusion.Electronic copies of references cannot be accepted due tocopyright restrictions.

References received by June 1, 2004, will be consideredfor inclusion in the 2005 LLSA module. Materials submittedafter that date may be considered for future LLSA tests.Recommendations may be submitted via fax to (517) 332-3943 or mail to LLSA References, American Board ofEmergency Medicine, 3000 Coolidge Road, East Lansing, MI48823.

If you have specific questions or comments contact TimothyJ. Dalton, Examination and Evaluation Project Specialist, at(517) 332-4800.

4th Annual New York State Regional SAEM Meeting

March 31, 2004; 8:00 am-2:00 pm

Hosted by: St. Luke’s-Roosevelt Hospital Center,Department of Emergency Medicine

Location: Lerner Hall, Morningside Campus,Columbia University, 114th Street and Broadway

Keynote Speaker: Glenn Hamilton, MD, Wright StateUniversity

Contact: Theodore C. Bania, MD, MS at RooseveltHospital, 1000 10th Ave., Department of EmergencyMedicine, Room GE01, New York, NY 10019 or toxtod@aol.com

Western Regional SAEM Meeting

April 3-4, 2004Oakland, CA

Hosted By: Highland General Hospital – Alameda County Medical Center,Department of Emergency Medicine

Location: Waterfront Plaza Hotel, Jack London Square 10 Washington StreetOakland, CA 94607

Contact: Robert Rodriguez, MD, IRBChairman Highland General HospitalDepartment of Emergency Medicine1411 E. 31st StreetOakland, CA 94602rrodriguez@hghed.com

14

ACADEMIC RESIDENTNews and Information for Residents Interested in Academic Emergency Medicine

Edited by the SAEM GME Committee

ABEM Certification and Recertification UpdateTrevor J. Mills, MD, MPHCharity HospitalFor the GME Committee

“The fall of Zion to the Machines” mumbled the residentas I prepared to give our program’s annual lecture on “howto prepare for the ABEM boards,” including the newEmergency Medicine Continuous Certification (EMCC).Disregarding the popular culture metaphor, I went on toexplain how the new and improved ABEM exam format willbe more interesting, educational and ultimately better, foradult learners and EM as a specialty.

It has been said “to understand the future, you mustunderstand the past.” The “official” history of the ABEMboards started with recognition by the American Board ofMedical Specialties in September of 1979. The originalqualifying pathways for the ABEM exam included eithersuccessful residency training, or clinical experience (5years and 5000 hours). As EM solidified its standing as aprominent medical specialty, and residency programsincreased in their numbers and size, the practice path wasclosed in 1988.

The current pathway to ABEM certification (followingsuccessful completion of residency) consists of a writtenexam and an oral exam. In the past, recertification couldbe obtained by either repeating a modified written exam orby re-taking the oral exam.

The initial post-residency exams will not change underthe current EMCC model. The written certification is, andwill remain a 6.5-hour test, which contains approximately335 single-best answer multiple-choice questions. Between10-15% of the questions include a visual stimulus. The oralcertification examination is, and will remain, a half-dayexam that includes 7 simulated patient encounters: 5 singlepatient and 2 multiple-patient encounters.

Over the last 23 years pass rates for the written boards(both residency trained and clinical pathway) have rangedfrom 52-78%. However, when focusing on EM residencytrained individuals, the pass rate is significantly higher (88-91%). A similar pattern is seen in the oral board results,when looking at both pathways, examinees have a 57-88%pass rate, however, residency trained individuals have an86-97% pass rate.

In this modern era, with the “rise of the machines” (com-puters) the opportunity for more frequent, relevant and cur-rent re-certification methods has become available. Thiscoupled with the newest concepts in adult learning mayhave stimulated the move to EMCC. The EMCC contains 4components: Professional Standing, Lifelong Learning andSelf Assessment (LLSA), Assessment of CognitiveExpertise and Assessment of Practice Performance.

Professional Standing basically boils down to having anactive US or Canadian medical license in good standing.

LLSA is where the revolution begins. The lifelong learn-ing portion consists of 20 readings posted on the ABEMwebsite each year. The readings are organized by topicand year (see Table 1). The readings will be a mix of orig-inal research and review topics pulled from a variety ofsources.

Table 1

Year Topic

2004 Thoracic-Respiratory, Immune System, Musculoskeletal

2005 Nervous System, Toxicology

2006 Traumatic, Cutaneous

2007 Signs, Symptoms, and Presentation, Psychobehavioral

2008 Procedures and Skills, Environmental

2009 Cardiovascular, Hematological

2010 Abdominal and Gastrointestinal, Other Components of Practice

2011 HEENT, Endocrine, Metabolic, Nutritional, Renaland GU

2012 Systemic Infectious Disorders, OB/GYN

The self-assessment portion of the LLSA consists of ayearly 40-question test based on the lifelong learning arti-cles. These questions are accessed from your home com-puter, at your leisure. You will have three chances to passeach yearly self-assessment exam.

The assessment of cognitive expertise is to be tested bythe ConCert exam. This exam will take place every tenyears, following your original board certification date. Inessence this takes the place of the current recertificationwritten boards. However, the ConCert will incorporate bothtraditional EM core knowledge topics and questions fromthe LLSA yearly tests. Unlike the LLSA yearly tests, youwill not be able to take the ConCert at home, rather you willhave to sign up for a half-day at a local computer testingcenter.

15

The final component of the EMCC is the assessmentof practice performance. This “yet to be determined” eval-uation tool will focus on practice improvement and willhave several ways to meet requirements. As the detailsare being worked on, the anticipated start date for this is2007.

So, now that we have a system that promotes life longlearning after residency, what do we do with it during res-idency? There are multiple ways to incorporate theEMCC into residency training. The LLSA articles couldbe presented during a dedicated lecture format on amonthly or quarterly basis. Alternatively, they could beintegrated into the weekly resident lecture series by spe-cific topic, eg., musculoskeletal into an ortho lecture, etc.Or, they could be incorporated into a journal club format.

For those individuals who prefer to study alone, or arepast the blissful years of residency training, the individualarticles can be downloaded for self study from the officialABEM website (www.abem.org) and can be found onseveral unofficial websites (www.emedhome.com).Several Board Review Courses also incorporate the arti-cles into their course material.

In summary, residency training, unchanged. Writtenand Oral boards after residency training, unchanged.Once you have your board certification, yearly tests canbe taken from your computer at home. Every ten years,a written board exam based on yearly readings, taken atyour local computer center. Starting in 2007, there will besome sort of practice performance evaluation.

The Resident Member of the SAEM Board of Directors: Seeing Past ‘The Meeting’

Valerie De Maio, MDUniversity of North Carolina, Chapel HillSAEM Board of Directors

Having been elected to the SAEMBoard of Directors last May was anhonor to say the least. Little did Iknow how illuminating the experiencewould be.

I have been a member of SAEM forseven years. As I knew it, SAEM wasthis great Annual Meeting: a yearlyget-together where we would shareour research, make new alliances,and catch up with old acquaintances.In fact, the only two times of the year Ireally gave SAEM much thought wereduring the holiday season (the infa-mous January abstract rush), and inthe spring as I prepared slides for theMay meeting. Now, having served onthe Board, I realize that SAEM meansso much more. SAEM is not just ameeting (though it is the highlight ofour academic year), nor is it simply agroup of researchers and educators.SAEM is a collective membership ofworkers and visionaries - forces ofchange and the future of our profes-sion.

The role of the SAEM Board ofDirectors is to organize the member-ship, guide their initiatives, and over-see the mission to promote academicemergency medicine by advancingresearch and education. Board mem-bers review issues, proposals, manu-scripts, and activities of the member-ship, committees, task forces, andinterest groups. I have learned thatour membership is extremely produc-

tive in this regard. As such, the bulk ofthe work of the Board is largely car-ried out through email exchange (Ihave gained a healthy new respect foremail). Monthly conference calls andmeetings are the forum for discussionand resolution of some of the morecomplex items and oftentimes thespringboard for new initiatives.

SAEM programs are numerous butI have come to realize that perhapsthere are just three areas of focus thatserve to further our mission. First,one of the greatest marks of SAEM isthe emphasis on its youngest mem-bers, encouraging those who haveembarked upon a career in emer-gency medicine toward leadershipand academic roles. All one must dois look to the SAEM website to find theabundant resources and opportunitiesavailable to the young EM enthusiast.Second, SAEM strongly values men-toring and encourages these relation-ships at all levels, from the undifferen-tiated medical student contemplatinga career in EM to the seasoned facul-ty member seeking promotion ortenure. When I searched the SAEMwebsite for the term ‘mentor’, 224 ref-erences were identified. The virtualadvisors group, academic careerguide, and faculty development web-site are only a few examples. Finally,SAEM is focused on the future.Significant thought is put to anticipat-ing the needs of our growing special-

ty. Presently SAEM is evaluatingmechanisms to increase researchfunding. SAEM has also partneredwith other EM organizations to fundthe dissemination of the Institutes ofMedicine study on the future of emer-gency care, which holds promise to bethe biggest thing to happen to ourspecialty since the 1994 Macy Report.

Having this look at the inner work-ings of our academic society has fur-thered my understanding of what itmeans to be a true EM academician.When I look around the table at theother members of the Board, I see myfuture. Board members come in allshapes and sizes: their experiencesare varied and their expertise wide-ranging. Each member has his or herown unique approach to dealing withthe issues. The common thread is theenthusiasm with which they set out tomeet the mission. As resident mem-ber, I am in a unique position to gath-er from this medley of mentors todevelop my own leadership style. Ihope that this will allow me to con-tribute more effectively to the special-ty in years to come. Appreciating thecurrency of the SAEM mission, I nowrealize that there may be anticipateddividends in having a resident partici-pate as a member of the board.

As always, I look forward to seeingyou all at The Meeting.

16

Principal Project End Awarding Investigator Award Title Institution Award Number Date Institution

Project Grants (61)Arzbaecher, Robert Subcutaneous Monitor/Alarm AJ Medical Engineering 5R43HL069608-02 5/31/2004 National Heart, Lung,

For Cardiac Arrest and Blood InstituteBaumlin, Kevin Prehospital Stroke Care: Mt. Sinai School of Medicine 2003 American Heart Association

strengthening the chainBecker, Lance 1. Optimizing Heart And University of Chicago 1. 1R01HL067630-01A1 1. 7/31/2007 1. National Heart, Lung, and

Brain Cooling During Cardiac Arrest Blood Institute2. Apoptosis And Oxidants After 2. 1R01HL071734-01 2. 7/31/2006 2. National Heart, Lung, and Murine Cardiac Arrest Blood Institute3. Impacts Of Alcohol / Fatigue On 3. 1R03HS011750-01 3. 9/29/2003 3. Agency for Healthcare Paramedic Skills Research and Quality

Bernstein, Edward 1. A Randomized Trial of the Brief Boston University 1. R01DA10792-06 A1 1. 11/30/2003 National Institute on Alcohol Negotiated Interview. Abuse and Alcoholism2. Ethnic and Racial Differences 2. R01DA10792-05 S1 2. 11/30/2003Among Cocaine and Heroin Users.

Bijur, Polly Racial And Ethnic Disparities In Yeshiva University 1R01HS013924-01 6/30/2006 Agency for Healthcare Research Acute Pain Control and Quality

Biros, Michelle Disparities In Emergency Health Care Society for Academic 1R13HS014030-01 5/14/2004 Agency for Healthcare Research Emergency Medicine and Quality

Boyer, Edward Relationship Between The Internet University of Massachusetts 5R21DA014929-03 8/31/2004 National Institute on Drug AbuseAnd Illicit Drug Use

Callaway, Clifton 1. Hypothermia And Gene Expression University of Pittsburgh 1. 5R01NS046073-02 1. 6/30/2006 National Institute of Neurological After Cardiac Arrest Disorders and Stroke2. Brain Ischemia And Map 2. 5K02NS002112-05 2. 6/30/2006Kinase Activation

Crain, Ellen Team Targeting The Environment Yeshiva University 5U01AI039900-05 7/31/2003 National Institute of Allergy and And Asthma Management Infectious Diseases

Daya, Mohamud Public Access Defibrillation Trial In Oregon Health Sciences University 2006 National Heart, Lung, and Blood Portland, Oregon Institute

D'onofrio, Gail Emergency Physician Brief Yale University 5R01AA012417-02 7/31/2004 National Institute on Alcohol Interventions For Alcohol Abuse and Alcoholism

Feldman, James 1. Testing Zafirlukast (Accolate) In Boston University 1. 5M01RR000533-350326 National Center for Research Subjects With Asthma Exacerbations Resources2. Sestamibi For Emergency Triage 2. 5M01RR000533-350317For Suspected Cardiac Ischemia Trial

Fleisher, Gary Research Training In Pediatric Children's Hospital (Boston) 5T32HD040128-03 4/30/2006 National Institute of Child Health Emergency Medicine and Human Development

Gesell, Laurie Beth Complementary Hyperbaric Oxygen University of Cincinnati 1R21CA102497-01 8/31/2005 National Cancer Institute,for Brain Radionecrosis National Institutes of Health

Gorelick, Marc PEAT: Pediatric Emergency Medical College of Wisconsin 5R03HS011395-02 9/29/2003 Agency for Healthcare ResearchAssessment Tool and Quality

Green, Gary 1. Coronary Thrombosis And Risk Johns Hopkins University 1. 5R01HL069746-02 1. National Heart, Lung, andIn The Emergency Department Blood Institute2. Training of hospital staff for disasters 2. U-01 8/31/2004 2. Agency for Healthcare

Research and Quality

Greenes, David Automated Lab Test Follow-Up To Children's Hospital (Boston) 1R03HS011711-01A1 9/29/2004 Agency for Healthcare ResearchReduce Medical Errors and Quality

Hoffman, Stuart Effects Of Dihydroepiandrosterone Emory University 5R03HD040295-02 3/31/2004 National Institute of Child Health On Brain Injury and Human Development

Howes, David A Rct Of Computer Screening For University of Chicago 5R01HS011096-03 8/31/2003 Agency for Healthcare Research Domestic Violence and Quality

Jauch, Edward Functional Proteomics Identification University of Cincinnati 5P50NS44283-02 8/2007 National Institute of Neurologicalof Serum Proteins Associated with Disorders and StrokeIntracerebral Hemorrhage Following Thrombolytic and Antiplatelet Therapy for Acute Ischemic Stroke

Kelen, Gabor Surge Capacity in Disasters Johns Hopkins University U-01 Agency for Healthcare Research and Quality

Kellermann, Arthur Progesterone Treatment Of Blunt Emory University 5R01NS039097-03 7/31/2004 National Institute of NeurologicalTraumatic Brain Injury Disorders and Stroke

Kline, Jeffrey 1. Pretest Probability Assessment For Carolinas Medical Center 1. 1R41HL074415-01 National Heart, Lung, and Blood Pulmonary Embolism Institute2. Surrogate Markers for Severe 2. 1RO1HL07438401 12/31/2003Pulmonary Embolism

Krause, Gary Suppression Of Protein Synthesis In Wayne State University 5R01NS033196-08 12/31/2003 National Institute of Neurological Reperfused Brain Disorders and Stroke

Lach, Thomas Lifebelt CPR: Combined Thoracic And Deca-Medics 1R41HL071378-01A1 4/30/2004 National Heart, Lung, and Blood Sternal Compression Institute

Li, Guohua 1. Alcohol And General Aviation 1. 5R01AA009963-10 1. 6/30/2004 1. National Institute on AlcoholAbuse and Alcoholism

2. Pilot Aging And Aviation Safety Johns Hopkins University 2. 2R01AG013642-06 2. 6/30/2008 2. National Institute on Aging

Lurie, Keith Impedance Threshold Valve For CPR X Llc 2R44HL065851-02 1/31/2004 National Heart, Lung, and Blood Improving Standard CPR Institute

McCarthy, Melissa Pediatric Injury Johns Hopkins University R-01 Agency for Healthcare Research and Quality

Principal Project End Awarding Investigator Award Title Institution Award Number Date Institution

Ma, Xin-Liang Peroxynitrite In Cardiac Ischemia/ Thomas Jefferson University 5R01HL063828-03 5/31/2004 National Heart, Lung, and Blood Reperfusion Injury Institute

Maitra, Subir Glu6pase And 6p2k/Fbase Gene State University New York 5R01GM058047-03 7/31/2004 National Institute of GeneralRegulation In Sepsis Stony Brook Medical Sciences

Mandl, Kenneth Disease Surveillance In Real Time: Children's Hospital (Boston) 1R01LM007677-01 6/30/2006 National Library of MedicineGeotemporal Methods

Markenson, David Pediatric Disaster Preparedness Columbia University 1R13HS013855-01 9/29/2003 Agency for Healthcare Research And Response Conference and Quality

Mosesso, Vince Public Access Defibrillation Trial University of Pittsburgh 12/2004 National Heart, Lung and Blood Institute

Neumar, Robert Calpain-Mediated Injury In University of Pennsylvania 5R01NS039481-04 4/30/2005 National Institute of Neurological Post-Ischemic Neurons Disorders and Stroke

Olson, James Mechanisms Of Cellular Taurine Wright State University 5R01NS037485-03 3/31/2004 National Institute of NeurologicalTransport In Brain Edema Disorders and Stroke

Regan, Raymond Effect Of Inducible Antioxidants Thomas Jefferson University 1R01NS042273-01A1 11/30/2006 National Institute of NeurologicalOn Hemoglobin Toxicity Disorders and Stroke

Richardson, Lynne Research Without Consent: Mount Sinai School of Medicine 1R01HL073387-01 6/30/2006 National Heart, Lung, and BloodThe Community Perspective of NYU Institute

Rothman, Richard 1. Evaluation Of Febrile Iv Drug Users-- 1. Johns Hopkins University 1. 5M01RR000052-420742 1. 6/30/2005 1. National Center for Research Guidelines For Emergency Management 2. Johns Hopkins University/ Resources2. Development of Diagnostic University of Maryland 2. AIO2031 2. 7/31/2008 2. NIAIDPlatforms for Bioterrorism Events

Segal, Gershon Endotoxin Assay For Analysis Johns Hopkins University 5M01RR000052-420803 National Center For Research Of Septicemia Damage Resources

Smith, Sharon Social Support And Education Washington University R01HL072919-01 3/31/2008 National Institute of HealthIn Asthma Follow-Up School Of Medicine

Stein, Donald 1. The Effects Of Progesterone Emory University 1. 5R01NS040825-02 1. 11/30/2004 1. & 2. National Institute of And Its Metabolites On Tbi Neurological Disorders and 2. Progesterone After Traumatic 2. 5R01NS038664-03 2. 1/31/2005 StrokeBrain Injury

Sullivan, Jonathon Cell Survival In Brain Reperfusion Wayne State University 5R01NS041919-03 6/30/2005 National Institute of Neurological Disorders and Stroke

Terndrup, Thomas 1. Innovative Education For University of Alabama At Birmingham 1. 9/15/05 1. Agency for Healthcare Bioterrorism Research and Quality2. Public Access To Defibrillation 2. 12/31/03 2. National Heart, Lung, and

Blood Institute

Thom, Stephen Co Poisoning In The Context University of Pennsylvania 5R01ES005211-14 7/31/2004 National Institute ofOf A Reperfusion Injury Environmental Health Sciences

Vanden Hoek, Terry Preconditioning Against A Source University of Chicago 5R01HL068951-02 5/31/2007 National Heart, Lung, and BloodOf Reperfusion Oxidants Institute

Warman, Matthew Lubricin In Articulating Joints Case Western Reserve R01AR050180-01 8/31/2008 National Institute of Arthritis,Gregory, Jay University and Rhode Musculoskeletal And Skin

Island Hospital Diseases

Wears, Robert 1. Human Factors And Usability Analysis University of Florida 5P20HS011592-02 1. 1/1/2004 1. ASHPOf Automated Dispensing Units2. Center For Safety In Emergency Care 2. 9/29/2004 2. Agency for Healthcare

Research and Quality

Willis, John Minimally Invasive Blood Lactate Mohawk Innovative Technology, Inc. 1R43HL072638-01 10/31/2003 National Heart, Lung, and BloodBiosensor Institute

Wright, Robert Core--Community Based Metals Harvard University 5P42ES005947-129004 3/31/2005 National Institute of Exposure In Child Development Environmental Health SciencesAnd Hearing

Yealy, Donald An Empiric Risk Stratification University of Pittsburgh 5R01HS010888-02 9/29/2003 Agency for Healthcare ResearchRule For Heart Failure and Quality

Young, Kelly Vp 63843 In Treatment Of Enteroviral Harbor-UCLA 5M01RR000425-340790Meningitis In Adolescents&Adults

Zink, Brian Short Term Training In Health University of Michigan 5T35HL007690-23 4/30/2006 National Heart, Lung, and BloodProfessional Schools Institute

Career Development Awards (19)Alessandrini, Evaline Predicting Vaccine Status & Ed Children's Hospital of Philadelphia 5K23HD001320-04 6/30/2005 National Institute of Child Health

Use In Medicaid Newborns and Human Development

Asplin, Brent Emergency Department Crowding: Health Partners Research 5K08HS013007-02 2/28/2007 Agency for Healthcare ResearchCauses And Consequences Foundation and Quality

Bazarian, Jeffrey Epidemiology Of Traumatic Brain Injury University of Rochester 5K23NS041952-02 8/31/2008 National Institute of Neurological Disorders and Stroke

Dickson, Eric Hormonal Opioids In Ischemic University of Massachusetts 5K08HL069834-02 5/31/2006 National Heart, Lung, and BloodPreconditioning Institute

Dorevitch, Samuel Demolition And Asthma In Chicago University of Illinois at Chicago 5K08ES011302-02 3/31/2007 National Institute ofPublic Housing Environmental Health Sciences

Grupp-Phelan, Jacqueline Screening Services In The Pediatric Children's Hospital 1K23MH063916-01 3/31/2008 National Institute of MentalEmergency Department Health

Hickey, Robert Cox-2 And Injury In The Children's Hosp ital 5K08HD040848-03 6/30/2006 National Institute of Child HealthImmature Brain and Human Development

17

18

Principal Project End Awarding Investigator Award Title Institution Award Number Date Institution

James, Laura Novel Therapies For University of Arkansas 5K08DK002971-03 11/30/2004 National Institute of DiabetesAcetaminophen Toxicity and Digestive and Kidney

Diseases

Jay, Gregory Immunoprobes For Lubricin From Rhode Island Hospital 1K08AG/AR01008-01 7/31/2004 National Institute on AgingHuman Synovial Fluid

Kaji, Amy Hospital Disaster Plans: Structure, Harbor-UCLA 1F32HS013985-01 6/30/2004 Agency for Healthcare ResearchTraining & Function and Quality

Porter, Stephen Informative Technology: Linking Parents Children's Hospital (Boston) 5K08HS011660-02 6/30/2005 Agency for Healthcare ResearchAnd Providers and Quality

Quinn, James A Network Of Research Units To University of California 5K23AR002137-04 3/31/2005 National Institute of Arthritis AndStudy Clinical Wound Care San Francisco/ Stanford University Musculoskeletal And Skin

Diseases

Rhodes, Karin Identifying And Responding To University of Chicago 5K23MH064572-02 6/30/2007 National Institute of MentalMale Partner Violence Health

Rothman, Richard Mentored Patient-Oriented Research Johns Hopkins University 5K23RR016070-04 6/30/2005 National Center For ResearchCareer Development Aw Resources

Strait, Richard Cytokines Regulation Of Anaphylaxis Children's Hospital (Cincinnati) 5K08AI050006-03 6/30/2004 National Institute of Allergy andIn The Mouse Infectious Diseases

Wright, Robert Neurochemical And Genetic Markers Brigham And Women's Hospital 5K23ES000381-03 8/31/2005 National Institute ofOf Lead Toxicity Environmental Health Sciences

Young, Kelly Mentored Patient-Oriented Research Harbor-UCLA 5K23RR016180-03 8/31/2005 National Center For Research Career Development Aw Resources

Younger, John 1. Lung Injury, Perfluorocarbons, University Of Michigan 1. 5K08HL003817-05 1. 1/31/2004 1. National Heart, Lung, and and Hemorrhagic Shock Blood Institute2. Protective Effects of anti-C5a in Sepsis 2. R01GM069438-01 2. 11/29/2008 2. National Institute of General

Medical Sciences

Non-NIH Grants (45) Angelos, Mark Reactive Oxygen Species In Low Ohio State University 6/2004 American Heart Association

Flow Ischemia

Barbee, Wayne Metabolic Engineering Strategies Virginia Commonwealth University 6/2004 Defense Advanced ResearchFor Cellular Stasis Projects Agency (DARPA)

Bernstein, Steve Strategies To Reduce Tobacco-Related Montefiore Medical Center 2005 American Legacy FoundationIllnesses In The Emergency Department

Rodney Boychuk Managing Pediatric Asthma: Emergency Kapi'olani Health Foundation 043505 1/31/2004 Robert Wood JohnsonDepartment Demonstration Program Foundation

Brown, Michael Asthma Surveillance And Intervention Michigan State University 2004 Centers for Disease Control andIn Hospital Emergency Departments Prevention

Cline, David Cardiovascular Surveillance Via Wake Forest University Ts 0769 9/29/2005 Centers for Disease Control andA Hypertension Registry Prevention

Degutis, Linda A Comparative Analysis Of Dwi Yale University 12/2004 Robert Wood JohnsonLegislation In The Us And Canada Foundation

Fein, Joel 1. Screening And Secondary Prevention University of Pennsylvania 37-01 1. 2/2005 1. Emergency Medical Services For Psychological Sequelae Of for Children/Health Resources Pediatric Injury and Services Administration2. Development Center For Traumatic 2. 9/2005 2. SAMHSAStress In Children3. Refusal And Attrition Among Youth 3. 1/2004 3. Firearm Injury Center (Ficap)Enrolled In a Home Based Violence Prevention Intervention

Hargarten, Stephen 1. Injury Research Center at the Medical College of Wisconsin 1. R49/CCR519614 1. 7/2006 Centers for Disease ControlMedical College of Wisconsin2. Analysis Of Violence Related Fatalities 2. R49/CCR519614 2. 7/2006And Injuries In Wisconsin

Ralph Hingson Peer-Based Intervention To Promote Boston University 043510 08/31/2004 Robert Wood JohnsonBehavior Change Among Youth In FoundationEmergency Departments Who Test Positive For Risky Drinking

Kelly, Kevin 1. Managing Pediatric Asthma: Medical College of Wisconsin 1. 043507 1. 9/30/2004 1. & 2. Robert Wood Johnson Emergency Department FoundationDemonstration Program 2. Allies Against Asthma: A Program To 2. 044214 2. 12/31/2004Combine Clinical And Public Health Approaches To Chronic Illness

Knox, Todd Pain and Emergency Medicine Initiative Emory University and 11/30/2004 The Mayday Fund, New York,American College of Emergency New YorkPhysicians

Lowe, Robert Cooperative Agreement between Oregon Health and Science University 8/31/2003 Environmental Protection Agency USEPA/CEPPO and Wharton Risk (EPA)Management Decision Process Center

19

Principal Project End Awarding Investigator Award Title Institution Award Number Date Institution

Maio, Ronald 1. Non-hospitalized traumatic brain injury: University of Michigan 1. R49/CCR523223-01 1. 9/30/2006 1. Centers For Disease Control Michigan incidence, impact, and cost (CDC)2. Great Lakes regional node for pediatric 2. U03MC00003-01 2. 9/30/2005 2. Department of Health and EMS research Human Services, Maternal Child

Health Bureau, Emergency Medical Services for Children

3. Methods to Determine the Value of EMS 3. 98-05117 3. 11/30/2005 3. NHTS/National Assoc. ofState EMS Directors

Macias, Charles Managing Pediatric Asthma: Baylor College of Medicine 043506 9/30/2004 Robert Wood JohnsonEmergency Department Demonstration Program Foundation

Meldon, Steve An Ed-Based Falls Prevention Screening Case Western Reserve University 7/2004 American Geriatrics SocietyAnd Referral Program and The John A. Hartfod

Foundation

Mello, Michael 1. Phone Intervention of ETOH Brown University 1. R49/CCR1232280-01 1. 9/2006 1. Centers for Disease Control use in ED MVC patients and Prevention2. Injury Free Coalition for Kids in 2. 047099 2. 11/2006 2. Robert Wood Johnson Providence at Hasbro Children’s Hospital Foundation

Rothman, Richard Rapid HIV Testing in the ED Johns Hopkins University 12/31/2005 Maryland Dept. of Health

Schull, Michael 1. Causes And Relationships Between University of Toronto 2006 Canadian Institutes of Health Overcrowding And Waiting In Different Research Emergency Departments: The Crowded Study.2. Pre-Hospital And Emergency Services In Canada.

Shah, Manish Prehospital Screening To Prevent Injuries University of Rochester 2005 Hartford Foundation/AmericanAnd Illnesses Geriatrics Society

Silvotti, Marco 1. "Is Etomidate Being Underdosed For Queen's University at Kingston 1. 2004 1. Ministry Of Health Of Ontario Emergency Rapid Sequence Intubation"; (Emergency Health Services

Branch)2. "Canadian Acetaminophen Overdose Study"; 2. 2004 2. Physicians' Services Inc

Foundation3. "Hepatotoxicity Following Therapeutic Doses Of Acetaminophen In Recovering Alcoholics"

Stern, Susan Optimizing Resuscitation For The Casualty University of Michigan 6.5 Years Department of Defense Office ofWith Combined Hemorrhagic Shock And Naval ResearchTraumatic Brain Injury

Stephen Teach Managing Pediatric Asthma: Children's Research Institute 043508 9/30/2004 Robert WoodEmergency Department Demonstration Program Johnson Foundation

Terndrup, Thomas 1. Rural Access To Emergency Devices 1. State Alabama Department 12/2006 1. Health Resources and2. Integrated Healthcare Leadership of Public Health ServicesTraining In Response To Weapons 2. Noble Training Center, Anniston, Alabama 2. AdministrationOf Mass Destruction Department of Homeland

Security

Wright, David Neurorehabilitation With Emory University 2003 National Center for Medical Progesterone And Pregnenolone Rehabilitation Research

The SAEM Newsletter is mailed every other month toapproximately 6000 SAEM members. Advertising is limit-ed to fellowship and academic faculty positions. Thedeadline for the May/June issue is April 1, 2004. All adsare posted on the SAEM website at no additional charge.

Advertising Rates:Classified ad (100 words or less)

Contact in ad is SAEM member $100Contact in ad non-SAEM member $125

Quarter page ad (camera ready)3.5” wide x 4.75” high $300

To place an advertisement, email the ad, along with con-tact person for future correspondence, telephone and faxnumbers, billing address, ad size and Newsletter issues inwhich the ad is to appear to: Carrie Barber atcarrie@saem.org

HHS Completes E-Grants SiteOrganizations interested in federal grants can now visit

one web site to find application materials and other relatedinformation. The Health and Human Services Departmentannounced the completion of www.grants.gov, a site pro-viding "one-stop" grants shopping. The site includes infor-mation about more than 800 grant opportunities at 26 agen-cies. Potential grant applicants can search Grants.gov toview listings of available funding. Once they have selecteda grants program, they can download applications and sub-mit the forms online. Not all agencies have posted applica-tion materials yet, but forms are available from HHS and theCommerce, Education, Energy and Justice departments.

2020

tragedy of the commons would be toinstitute negative social or financialincentives to reduce inappropriate useof EMS or emergency departmentresources. Such an approach raises dif-ficult ethical issues regarding the rightsof individuals to access medical carefreely versus the rights of the populationas a whole to have high-quality emer-gency care available when needed.There are a number of related and verydifficult research questions which wouldneed to be addressed regarding the def-inition and detection of inappropriateuse and the reliability and validity of anymeasures used to define inappropriateutilization.

Examples of this approach includesthe use of small financial co-paymentswhich could be refunded if a patientrequires admission to the hospital fromthe emergency department.Interestingly, emergency physiciansoften react emotionally to such solu-tions, and often believe that this reactionis in the best interest of their patients. Intruth, however, some approach to man-age the commons that is emergencycare will be required if we are to pre-serve the quality of emergency care forall patients. In other words, we musttake an active role to managing thecommons if we are to preserve it, ratherthan reacting negatively and emotional-ly towards any attempt to manage it.

Focusing on the development ofresearch capability within a department,active management of each limitedresource is again the key. This mayinclude active management of a men-tor’s time, active management of pro-tected time, and the active managementof other resources (e.g., funds fortuition, equipment, and support person-nel). Such an approach requires “mutu-ally agreed upon” sacrifice by others inthe department, and in the institution, sothat adequate resources can be identi-fied to allow an intensive and sustainedinvestment in the initial research careerof young investigators. Without such aninvestment, however, we will be consis-tently setting up our young investigatorsto fail, and then finding external excusesto explain their failure.

In summary, in a setting of limitedresources, a blind devotion to equal allo-cation of resources severely limits theresearch potential of a department.Since an adequate investment in apromising young investigator mustoccur early in their career, be sustained,

and be intensive, this can only occurwith a mutually agreed upon sacrifice byothers in the department. Thus, supportof colleagues is critical and, in manydepartments, such support will notoccur without a fundamental change inthe culture of the department.

Closing ThoughtsWhile I take personal pride in the tra-

dition of equal and unfettered access tomedical care that characterizes emer-gency medicine, we must learn the les-sons taught by the Tragedy of theCommons if we are to preserve thequality of this care for those who need it.This will require active management oflimited resources, rather than a single-minded devotion to equality and unfet-tered access. Likewise, if we are to real-istically and meaningfully support thedevelopment of research capability with-in emergency medicine, we must bewilling to disproportionately shiftresources, whether they are a mentor’stime or protected academic time, to ourpromising young investigators. This willrequire a sacrifice by many so that a fewmay push the limits of our academicspecialty.

[Editor’s note: The biologist who wrotethe landmark 1968 article on theTragedy of the Commons recentlypassed away.10]

References1. Hardin G. The Tragedy of the

Commons. Science 1968;162:1243-1248.

2. Hardin G. Extensions of “TheTragedy of the Commons.” Science1998;280:682-683.

3. Kennedy D. Sustainability and theCommons [Editorial]. Science2003;302:1861.

4. Dietz T, Ostrom E, Stern PC. TheStruggle to Govern the Commons.Science 2003;302:1907-1912.

5. Adams WM, Brockington D, DysonJ, Vira B. Managing Tragedies:Understanding Conflict overCommon Pool Resources. Science2003;302:1915-1916.

6. Mascie-Taylor CGN, Karim E. TheBurden of Chronic Disease.Science 2003;302:1921-1922.

7. 42 CFR §489.248. Blanda M, Gerson LW, Dunn K.

Emergency Medicine ResidentResearch Requirements andDirector Characteristics. Academic

Emergency Medicine 1999;6:286-291.

9. NIH National Research ServiceAward Institutional ResearchTraining Grants. Accessed athttp://grants1.nih.gov/grants/guide/pa-files/PA-00-103.html onFebruary 1, 2004.

10. Holden C. “Tragedy of theCommons” Author Dies. Science2003;302:32.

Table. Key Elements of ResearchTraining.• Access to Formal Coursework• Mentor• Protected time• Facilities, equipment, and supplies• Supportive environment (mentor,

chair, colleagues)

Figure. Departmental ResearchDevelopment.

“Tragedy of the Commons” (Continued)

NewsletterSubmissionsWelcomed

SAEM invites submissions to theNewsletter pertaining to academicemergency medicine in the followingareas: 1) clinical practice; 2) educa-tion of EM residents, off-service resi-dents, medical students, and fellows;3) faculty development; 4) politicsand economics as they pertain to theacademic environment; 5) generalannouncements and notices; and 6)other pertinent topics. Materialsshould be submitted by e-mail tosaem@saem.org. Be sure to includethe names and affiliations of authorsand a means of contact. All submis-sions are subject to review and edit-ing. Queries can be sent to theSAEM office or directly to the Editorat david.cone@yale.edu.

21

FACULTY POSITIONSCONNECTICUT: University of Connecticut/Hartford Hospital:Section Head--PreHospital Programs. Senior administrative faculty position to oversee all aspectsof Ground and Air EMS. Multi Hospital program with 100,000+ patient visits, 36EM residents, fellowships, two helicopters. Reply to Robert D. Powers MD MPH,Professor and Chief of EM--email:Rpowers@Harthosp.org

MICHIGAN: Michigan State University – Kalamazoo Center for Medical StudiesThe Department of Emergency Medicine is seeking a Director of PediatricEmergency Medicine to serve as academic faculty for our emergency medicineresidency program. Candidates must be BC/BP in emergency medicine, as wellas BC/BP in pediatrics or pediatric emergency medicine. This exciting opportu-nity involves outstanding compensation and benefits, protected academic time,and a delightful university community in which to live and work. Please contact:David Overton MD, MBA, Michigan State University - Kalamazoo Center forMedical Studies, 1000 Oakland Drive, Kalamazoo, MI 49008

NEW JERSEY: UMDNJ (Newark) – Come in on the ground floor at a major med-ical school and university hospital. We're planning to start an EM Residency andhave faculty opportunities for Emergency Physicians at ALL LEVELS, includingResidency Director, EMS Director and Director of Clinical Operations. The EDhas an annual volume of 72,000, including 2,700 level I trauma patients.Competitive compensation and benefits package including on-site fitness and-child care centers. For information please contact Ronald Low, MD, MS, at 973-972-7882. UMDNJ-University Hospital is an AA/EOE, M/F/D/V. Visit us on theweb at www.TheUniversityHospital.com.

OHIO: The Ohio State University - Assistant/Associate or Full Professor.Established residency training program. Level 1 Trauma center. Nationally rec-ognized research program. Clinical opportunities at OSU Medical Center andaffiliated hospitals. Send curriculum vitae to: Douglas A. Rund, MD, Professorand Chairman, Department of Emergency Medicine, The Ohio State University,146 Means Hall, 1654 Upham Drive, Columbus, OH 43210, emailDailey.1@osu.edu, or call (614) 293-8176. Affirmative Action/EqualOpportunity Employer.

OREGON: Fellowship: Combined EMS/ Emergency Preparedness Education fel-lowship available as of June 30, 2004. OHSU has an Emergency Medicine resi-dency in a level I trauma center and tertiary pediatric hospital, and is the hometo a tri-state regional poison control center, a multi-county base for EMS opera-tions and training, an original site for MMRS disaster preparedness, and facultywith expertise in infectious, chemical, and nuclear injury. We are expanding ourmission to be a center of expertise in bioterrorism preparedness and training,and seek an EM trained individual for a 1 to 2-year fellowship. Opportunitiesalso exist to combine the fellowship experience with MPH degree or diplomaprograms in clinical research, public health, health policy, epidemiology, andinformatics. Please contact Zane Horowitz, horowiza@ohsu.edu or MohamudDaya, dayam@ohsu.edu.

OREGON: The Oregon Health & Science University, Department of EmergencyMedicine is conducting an ongoing recruitment campaign for talented facultymembers. Entry-level clinical faculty members at the instructor and assistantprofessor level. Preference given to those with fellowship training (especially inpediatric emergency medicine) or equivalent experience. Knowledge of emer-gency medicine as a faculty discipline is expected. Please submit a letter ofinterest, CV, and the names and phone numbers of three references to: JerrisHedges, MD, MS, Professor & Chair, OHSU Department of EmergencyMedicine, 3181 SW Sam Jackson Park Road, CDW -EM, Portland, OR 97239-3098.

PENNSYLVANIA: Penn State University College of Medicine & Hershey MedicalCenter – Department of Emergency Medicine is seeking to add experiencedacademic emergency physicians to our internationally known faculty. We areseeking faculty to supplement our research and educational missions and par-ticipate with our newly approved PENN STATE EMERGENCY MEDICINE RESI-DENCY. Physicians must be board certified with some academic experience.Faculty rank will be commensurate with experience. Confidential inquiry toKym Salness, M.D. (Chair) or Christopher J. DeFlitch, M.D. (Vice-Chair),Department of Emergency Medicine, P.O. Box 850 (H043), Hershey, PA 17033,Phone (717) 531-8955 or email cdeflitch@psu.edu or www.pennstateemergen-cymedicine.com. AAEOE. Women and minorities are encouraged to apply.

The Department of Emergency Medicine of Texas TechUniversity School of Medicine is seeking an experiencedEmergency Medicine residency trained physician to assumeleadership of it’s residency program. The program is over twen-ty years old, fully accredited and has twenty-four residents atpresent. The candidate would join 15 EM physicians in theDepartment. Our mission is to prepare residents to be able topractice in any ED in the country. The Department is located inEl Paso, Texas and will soon be incorporated into the new 4 yearmedical school just approved by the state legislature. Our newoffices are under construction on campus and a new $36 millionresearch building is in late design phase for the campus. Ourmain ED is at Thomason Hospital with a patient volume of60,000 visits last year. It is a Level I Trauma Center and is open-ing a new $25 million wing, including the ED Observation Unitnext year. For more information on the residency visithttp://www.elp.ttuhsc.edu/em

Please send a letter, or email, expressing interest to: Matthew J.Walsh, MD, Associate Professor and Chair, Dept. of EM, 6090Surety Dr. #412, El Paso, Texas 79905. Emailmwalsh1@elp.rr.com or phone 915-771-6482.

Texas Tech University is an Equal Opportunity Employer.Women and minorities are encouraged to apply.

ASSOCIATE RESIDENCY DIRECTOR

We are recruiting an Associate Residency Director foran established EM program. The University ofRochester is a Level 1 Trauma Center with 90,000visits per year. We currently have 30 residents andfellowships in Pediatrics, Sports Medicine and EMS.

Applicants with enthusiasm for teaching, excellentorganizational skills and an interest in high fidelitysimulation should apply. Applicants must be EMresident trained. Protected time for administrativeduties provided.

University of Rochester is an equal opportunityemployer.

Contact:Sandra Schneider, M.D., ChairDepartment of Emergency Medicine,University of Rochester601 Elmwood Avenue, Box 655Rochester, NY 14642.Phone (585) 275-9490; fax (585) 506-0052;E-mail: Sandra_Schneider@urmc.rochester.edu

22

Louisiana State UniversityHealth Sciences Center

Shreveport, Louisiana

Medical Director of Clinical Services

The Department of Emergency Medicine at Louisiana StateUniversity Health Sciences Center is seeking a full-timefaculty to serve as Medical Director of Clinical Services forour academic department that will begin a residency train-ing program July 2004. LSUHSC is the tertiary referral cen-ter for entire region with annual volume of 60,000 andserves as the only Level I Trauma Center in the area.Interested individuals should be EM residency trained andboarded with a strong background in process improvementand excellent people skills. This is a great opportunity forinvolvement in both resident education and medical direc-tion from the very beginning. LSUHSC is an EqualOpportunity/Affirmative Action employer.

Applicants should contact:Thomas C. Arnold, M.D.Chairman, Department of Emergency MedicineLSUHSC-Shreveport1501 Kings HighwayP.O. Box 33932Shreveport, LA 71130-3932(318) 675-6885 or fax (318) 675-6878

23

Newark Beth Israel Medical CenterAn Affiliate of the St. Barnabas Health Care System

Department of Emergency Medicine

Director of Academic AffairsWe are searching for an emergency medicine physicianexperienced in research, academics, grant writing, and res-idency administration to assume a key leadership role in ourdepartment. We are looking for an enthusiastic, energeticindividual who is 5-10+ years post-EM residency graduationand desires an opportunity to lead a team of talented, ded-icated faculty and be part of an Emergency Departmentcommitted to scholarship, clinical excellence, communityservice, and humanistic values. An MS or MPH and/orexpertise in medical toxicology or ultrasound would be avery desirable plus. Academic appointment at the MountSinai School of Medicine. Applicant must be able to quali-fy at the Associate Professor or Professor level. This posi-tion carries a very competitive compensation package andample protected time commensurate with experience andseniority. Please contact or forward your CV/letter of inter-est to Marc Borenstein, MD, Chair, Department of EM,Newark Beth Israel Medical Center, 201 Lyons Ave, Newark,NJ 07112, phone - (973) 926-7562, e-mail - mboren-stein@sbhcs.com.

Take Pride. Take Ownership. Deliver Excellence.Patients 1st.

Faculty PositionsIn conjunction with starting Iowa’s first ACGME accredited EmergencyMedicine training program and academic Department of EmergencyMedicine, the University of Iowa is actively seeking clinical and tenuretrack faculty members to fill newly created core faculty positions.Competitive applicants will have completed an ACGME accredited emer-gency medicine residency-training or pediatric emergency medicine pro-gram and be actively participating in research or residency training.Qualified individuals will receive significant release time to develop theiracademic interests. Clinical duties will be performed at the University ofIowa Health Care’s Emergency Treatment Center; the regions only levelone trauma center. Successful applicants interested in either basic sci-ence or clinical research careers will be aligned with an appropriate NIHfunded mentor and receive considerable start up funds to jump-start theiracademic career. Iowa City is a beautiful outdoor and family orientedcommunity located along the banks of the Iowa River just 200 miles westof Chicago and was recently named the number 6 city to live in by Men’sJournal. Applicants should send a CV to Eric Dickson, M.D., Director,Program in Emergency Medicine, University of Iowa Hospitals and Clinics,200 Hawkins Drive – Rm. 1193 RCP, Iowa City, IA, 52242-1009. TheUniversity of Iowa is an Equal Opportunity and Affirmative ActionEmployer. Women and minorities are strongly encouraged to apply.

24

The Mount Sinai School of Medicine Department of Emergency Medicine is pleasedto offer a two-year research fellowship position to begin in July 2004.� Research project will be tailored to the interest of the research fellow and his/her

long-term career plans.� Opportunity to attend academic classes leading to a Masters Degree in Public

Health or Clinical Research.� Fellows will be mentored and supported in the preparation of research grant

applications appropriate to their experience and interests.� Limited clinical responsibilities at one of our five affiliated hospitals� Participation in training medical students and EM residents� Academic appointment in the Department of Emergency Medicine

The successful applicant will have completed residency training in EmergencyMedicine at an accredited program and will have demonstrated interest and/orexperience in biomedical, clinical or health services research. Interested individualsshould send a Curriculum Vita, names and contact information of three references,and a letter describing their qualifications and interests. An interview will berequired. Women and minorities are encouraged to apply.

To apply or to obtain more information contact the Research Fellowship Director:Lynne D. Richardson, MD at: lynne.richardson@mssm.edu.

The Mount Sinai School of Medicine is an equal opportunity employer.

Emergency Medicine Research Fellowship

Emergency Medicine Faculty Position

The Department of Emergency Medicine at the Boston University School ofMedicine (BUSM)) seeks academic faculty members. Positions are availableat Boston Medical Center (BMC) which is a Level 1 Trauma Center with124,000 visits annually. The Department of EM serves as an independentacademic department within BUSM and BMC.

The department has a nationally recognized, well-established residencyprogram with academic faculty appointments through BUSM. BMC is themedical control and academic base for Boston EMS. In addition, we have anactive research section with particular focus on public health, administration,EMS and cardiovascular emergencies. Candidates must be ABEM boardcertified or eligible and must demonstrate a commitment to the training ofemergency medicine residents. Competitive salary with an excellent benefitspackage.

Further information contact: Jonathan Olshaker MD, Professor and Chair,Department of Emergency Medicine, Boston Medical Center, 1 BMC Place,Boston MA 02118-2393. Tel: 617-414-5481; Fax: 617-414-7759; E-mail:olshaker@bu.edu. An Equal Opportunity/Affirmative Action Employer.

The Department of Emergency Medicine at the Boston University School ofMedicine (BUSM)) seeks academic faculty members. Positions are availableat Boston Medical Center (BMC) which is a Level 1 Trauma Center with124,000 visits annually. The Department of EM serves as an independentacademic department within BUSM and BMC.

The department has a nationally recognized, well-established residencyprogram with academic faculty appointments through BUSM. BMC is themedical control and academic base for Boston EMS. In addition, we have anactive research section with particular focus on public health, administration,EMS and cardiovascular emergencies. Candidates must be ABEM boardcertified or eligible and must demonstrate a commitment to the training ofemergency medicine residents. Competitive salary with an excellent benefitspackage.

Further information contact: Jonathan Olshaker MD, Professor and Chair,Department of Emergency Medicine, Boston Medical Center, 1 BMC Place,Boston MA 02118-2393. Tel: 617-414-5481; Fax: 617-414-7759; E-mail:olshaker@bu.edu. An Equal Opportunity/Affirmative Action Employer.

Director of PediatricEmergency Medicine The Department of Emergency Medicine at Maine MedicalCenter is seeking a full-time Director of Pediatric EmergencyMedicine to join an accomplished and growing academic facul-ty at our full-service tertiary care medical center. In addition tothe commitment to excellent patient care, education and schol-arly production shared by our entire group, this individual

will have the privilege of building a “Center for Excellence inPediatric Emergency Care” – a program that has been endorsed

and funded by hospital leadership. Candidates must be board-certified or prepared in Emergency Medicine with additional training ineither Pediatrics or Pediatric Emergency Medicine.

Maine Medical Center is a 606-bed tertiary care and teaching hospitalwith a multi-state referral base located in Portland, Maine. Our institu-tion is home to an outstanding emergency medicine residency programas well as a broad spectrum of independent residencies and fellowships.Emergency Medicine faculty hold academic positions at the Universityof Vermont School of Medicine.

Portland offers one of the country’s most picturesque coastlines on theeastern seaboard with countless recreational activities and a wealth ofcultural attractions. This is truly a wonderful place to live and practiceemergency medicine.

Interested candidates should send a cover letter and curriculum vitae to:Michael A. Gibbs, MD, Chief, Department of Emergency Medicine,Maine Medical Center, 22 Bramhall Street, Portland, ME 04102; Phone: 207-842-7010; Fax: 207-842-7025. EOE.

Participating member of the Diversity Hiring Coalition of Maine.

Y O U R P L A C E I S A T

The MaineHealth Family

WWW.MMC.ORG

Pediatric EM Faculty Position

Penn State's Milton S. Hershey Medical Center, Department ofEmergency Medicine and Penn State Children's Hospital in Hershey,PA is seeking a Pediatric Emergency Medicine academic faculty to jointhe Emergency Medicine faculty. The applicant should be trained inpediatric emergency medicine and would have the opportunity for dualappointments in the Department of Emergency Medicine, andPediatrics. As the only Children's Hospital between Pittsburgh andPhiladelphia, with a Level 1 Pediatric trauma center, we train high qual-ity residents in the Penn State Emergency Medicine and Pediatric res-idencies, as well as students from the Penn State College of Medicine.With a growing census of 46,000 per year, 23% of which are complexand routine pediatric patients, we are expanding our faculty and spacededicated to Pediatric Emergency Medicine. The Department ofEmergency Medicine also boasts of a strong ultrasound, ground EMS,areomedical helicopter and observational medicine programs. Thereis an outstanding and expanding 15-person, faculty group. This oppor-tunity combines comprehensive university health care, a medicalschool, an attractive small community lifestyle, excellent schools, andfabulous recreational and cultural opportunities in south centralPennsylvania. There are ample opportunities for clinical research, ifinterested. Contact Kym A. Salness, M.D., FACEP, Chair orChristopher J. DeFlitch, M.D., Vice-Chair, Department of EmergencyMedicine (H043), PO Box 850, Hershey, PA 17033 - phone (717) 531-8955 or e-mail at cdeflitch@psu.edu. The Penn State University MiltonS. Hershey Medical Center is an affirmative action/equal opportunityemployer. Women and minorities are encouraged to apply.

EMERGENCY MEDICINE RESIDENCY DIRECTOR

University Physician Associates, the faculty practice planfor the University of Missouri-Kansas City School ofMedicine, is seeking a new emergency medicine resi-dency director. The program, clinically based at TrumanMedical Center, was established in 1973 and currentlyadmits 9 residents per year into its EM-1,2,3 curriculum.The ED has an annual patient census of 56,000, and iscurrently undergoing a $15 million expansion which willnearly double its capacity. Expansion of faculty and res-ident complements is in the planning stages. TheSchool of Medicine recently purchased a medical simu-lator for the department with the expectation that we willcreate a center of excellence in undergraduate andgraduate medical simulation. The successful candidatewill have a minimum of three years experience as anassistant or associate program director, and will have ademonstrated track record of scholarly achievement inthe area of education. Salary, benefits, and academicrank will be commensurate with experience and achieve-ment. Send CV and letter of interest to: Robert A.Schwab, MD, Professor and Chair, Department ofEmergency Medicine, 2301 Holmes Street, Kansas City,Missouri 64108. Robert.Schwab@tmcmed.org

25

26

2004 AACEM Annual Meeting and WorkshopSaturday, May 15, 2004

Annual AACEM Educational Session (attendance limited to AACEM members and an AACEM member guest)7:00 am Continental Breakfast

7:30 am Review of Schedule; Introductions

8:00 am Keynote Speaker - Michael O'Connor Michael O'Connor is the Chair of the first Department of Emergency Medicine in Canada and is the Chair ofthe Emergency Medicine Program Committee for the Royal College of Physicians and Surgeons of Canada(a body that fulfills RRC and ABEM roles for Emergency Medicine). He will provide an overview of the devel-opment of academic emergency medicine in Canada. He will address the challenges for the future and relat-ed strategies for the development of academic emergency medicine in Canada.

9:15 am Moderated Topics (speakers)Faculty Incentives and Rewards - Frank PettyjohnFaculty Evaluation - Waste of Time or Motivational Tool? - Sandra SchneiderDifficult Faculty Member - Arthur KellermannStrategies for Aging Faculty Members - Norman ChristopherCare and Feeding of the Dean - Barry BrennerAlternative/Innovative Programs for Support of the Academic Department - Robert ShesserPreserving the Academic Mission in Difficult Fiscal Times - Brooks BockEstablishing Endowments - Why and How - Francis Counselman

11:30 am Brief Late-Breaking Topic Presentation

Annual AACEM Business Meeting (AACEM members only)12:00 pm Annual Business Meeting - Lunch

AACEM New and Future Chairs of Emergency Medicine WorkshopAACEM is pleased to offer the New and Future Chairs Workshop on May 15, 2004 in Orlando. This program has recruited

Emergency Medicine exemplar leaders who will discuss critical issues that can contribute to becoming a successful academicchair and leader in Emergency Medicine. An informal gathering will immediately follow the last session.

1:30-2:30 pm Leadership Principles and Skills: how to be a successful chair and leader and avoid failure, JohnMarx, MD, Carolinas Medical Center and Glenn Hamilton, MD, Wright State UniversityThis leadership session is focused on models of chair successes and ways to avoid failures. The philosophyof departmental leadership (e.g., "lead by example", "lead by consensus") and the role of other departmentalleaders such as residency program director, vice-chair, operations chief will be discussed. Group dynamicsand personality types; institutional hierarchy; serving as a "change leader" and overcoming institutional iner-tia; and conflict resolution techniques are just some of the content areas to be explored.

2:30-3:30 pm Advancing Emergency Medicine in Medical Schools/Hospitals/Practice Plans: Insights/Advice, LewisGoldfrank, MD, Bellevue Hospital Center and Brooks Bock, MD, Wayne State UniversityIn this session, negotiating principles, development of allies, neutralizing enemies, use of institutionalresources, and developing an academic base will be discussed. The session presenters are experiencedEmergency Medicine leaders who will share their experiences and lessons.

3:30-4:30 pm Business and Finance: how to assure a successful bottom line, Jerris Hedges, MD, MS, Oregon Healthand Science University and Nicholas Benson, MD, MBA, East Carolina UniversityIn this session, mission based administration, faculty incentive/bonus plans, and budget negotiations will bediscussed. This session will build on the experience of these physician leaders in their respective depart-ments and medical schools

All SAEM members and others are invited to attend this Workshop. The registration fee is $100 (refundable to AACEM membersafter verification of attendance). To register, send an email to saem@saem.org stating you would like to attend the Workshop andindicate your method of payment. Checks should be made payable to AACEM and mailed to 901 N. Washington Ave., Lansing,MI 48906.

Health care continues to change and emergency department resources are being stretched to their limits, if not beyond.Academic physicians are frequently being asked to participate in the daily management and operations of various clinical activi-ties, yet they have little management training. The goal of this physician developed and tested curriculum is to introduce funda-mental business and managerial tools to the academic emergency physician. This session has been developed by SAEM as aspecial pre-day offering at the 2004 Annual Meeting in Orlando.

This program is a condensed version of the University of Michigan management training program which has been delivered toover 500 physicians within various Health Systems across the USA. The course condenses the first-year MBA curriculum into atightly packed one-day curriculum as applied to Integrated Health Systems. While the roots of the program are derived from anacademic perspective, the design and delivery are relevant to both academic and community settings. The goal of this curricu-lum is to provide the clinician and administrator (Chair and Clinical Director) with the necessary tools to change their practice tooptimize the delivery of health care tomorrow. This course delivers content on the basic economics of health care, cost account-ing, operations management, finance, reimbursement and risk management, and physician leadership. Real emergency depart-ment financial and operational metrics data and examples will be presented throughout the course. Upon completion of thiscourse, attendees will be armed with tools to optimize health care delivery and enhance their ability to conduct research and edu-cation in ED operations management. The target audience is mid-level to senior physicians (clinical and administrative) andadministrative personnel. The registration fee is $200 and interested individuals can register via the online Annal Meeting regis-tration form at www.saem.org.

8:30 – 9:10 Economics, cost accounting, and risk management: This session begins with an introduction to the hospital’s costDavid Butz accounting system and the underlying economics of health care costs. Concepts include activity-based costing, direct and

indirect costs, fixed and variable cost, average and marginal cost, and opportunity cost. We will also break out payment and profit margins under traditional fee-for-service insurance, DRG-based payments, and “capitated” reimbursement -- while showing the risks inherent in each arrangement, the incentives created (good and bad), and some repercussions for physicians.

10:30 – 11:30 Applied operations management: This session includes three brief segments. First, it elaborates on some elements of David Butz activity-based costing that were not covered during the first lecture. Second, it discusses how physicians could creatively

make more intensive use of their fixed capacity. Third, it illustrates how physicians might make use of financial data as a research tool.

11:30 – 12:30 Integrating business principles into the delivery of care: Open analysis and different thinking can improve the quality Paul Taheri of care while markedly reducing costs. Physicians need information that provides a healthy tension between resource use

and quality of care.

1:30 – 2:30 Health system strategies demystified: In this module we look at investments made by health systems and the rationale David Butz utilized to justify these investments.

2:50 – 3:45 Clinical examples of applied business principles: This module provides a walk-through of some real life examples ofPaul Taheri programs that have been developed and implemented within a health system. The benefits, risks, and pitfalls are high

lighted.

3:45 – 4:45 Physician leadership: This session addresses how physicians can create learning organizations that enable effective, Paul Taheri efficient delivery of quality healthcare, and identifies the role in developing leadership in the enterprise.

4:45 – 5:15 Roundtable discussion: This forum provides an opportunity for the course participants to ask detailed questions of the faculty.

Course Faculty Paul A. Taheri, MD, MBA: Dr. Taheri graduated medical school from New York University in 1988 and completed a general sur-gical residency at Tulane University in 1994. He completed his MBA from the University of Michigan Business School (UMBS) in1999. He is currently the Division Chief of Trauma Burn Surgery and the Associate Dean for Academic Business Development.Together with David Butz, he is the founder and Co-director of the Center for Health Care Economics, a University of MichiganBusiness School and Medical School joint initiative.David A. Butz, PhD: Dr. Butz received his PhD in Economics in 1986 from Northwestern University. He served on the faculty ofthe Economics Department at the University of California at Los Angeles from 1987-1994 and on the University of Michigan fac-ulty from 1994 to present. At the Business School, he has taught core Applied Microeconomics and Operations Management to1st-year MBAs, and a 2nd-year MBA elective on Distribution and Supply Chain Management. He has won many teaching awards,and in 1995 the UMBS MBA students voted him Professor of the Year. Business Week’s Guide to the Best Business Schools hasidentified him as one of Michigan’s best teachers. He was also singled out for teaching excellence by students at UCLA andNorthwestern. He has participated in executive education and distance learning pilot projects that have utilized videoconferenc-ing and Internet delivery. He now serves on the faculty of the Department of Surgery at the University of Michigan Medical School,where his research and teaching focus on health care economics and outcomes research. Together with Paul Taheri, he is thefounder and co-director of the Center for Health Care Economics. His other research expertise lies in industrial organization, law& economics, antitrust, and supply chain contracting, where he has published numerous peer-reviewed articles on those topics.

27

The Business Aspects of Health System Management: The Emergency Physicians’ Role in Health System Leadership

May 15, 2004 (day before SAEM Annual Meeting)

Board of DirectorsDonald Yealy, MDPresident

Carey Chisholm, MDPresident-Elect

James Adams, MDSecretary-Treasurer

Roger Lewis, MD, PhDPast President

Valerie DeMaio, MDLeon Haley, Jr, MD, MHSAGlenn Hamilton, MDStephen Hargarten, MD, MPHKatherine Heilpern, MDJames Hoekstra, MDSusan Stern, MD

EditorDavid Cone, MDDavid.Cone@yale.edu

Executive Director/Managing EditorMary Ann Schroppmschropp@saem.org

Advertising CoordinatorCarrie BarberCarrie@saem.org

“to improve patient care byadvancing research andeducation in emergencymedicine”

The SAEM newsletter is published bimonthly by the Society for Academic EmergencyMedicine. The opinions expressed in this publication are those of the authors and donot necessarily reflect those of SAEM.

Society for AcademicEmergency Medicine901 N. Washington AvenueLansing, MI 48906-5137

PresortedStandard

U.S. PostageP A I D

Lansing, MIPermit No. 485NEWSLETTER

Newsletter of the Society for Academic Emergency Medicine

SAEM NEWSLETTER

Advertising Positions Availableat Annual Meeting

SAEM is again offering an opportunity to advertise inthe on-site program. The Annual Meeting will be heldMay 16-19 in Orlando and will attract approximately1,800 academic emergency physicians.

A limited amount of space is being set aside for theposition available section and only academic positionsavailable will be accepted. The deadline for receipt ofads at the SAEM office is April 23. Please email ads tocarrie@saem.org.

The following ad requirements and prices are availablefor the on-site program:

Classified line ads (100 words maximum):$100 (contact SAEM member)or $125 (non-SAEM member)

Quarter page ads: 31⁄2” wide x 43⁄4” deep $300Half page ads:71⁄2” wide x 43⁄4” deep or31⁄2” wide x 93⁄4” deep $350Full page ads: 71⁄2” wide x 93⁄4” deep $450

A typesetting fee ($25-$50) will be charged if thequarter, half, or full page ads are not camera-ready.

Keep Your Membership Mailings Coming!Be sure to keep the SAEM office informed of changes in your address, phone or fax numbers, and especially your e-mailaddress. SAEM sends infrequent e-mails to members, but only regarding SAEM issues or activities. SAEM does not sell orrelease its mailing list or e-mail addresses to outside organizations. Send updated information to carrie@saem.org

Call for Abstracts14th Annual Midwest Regional

SAEM MeetingSeptember 9-10, 2004

The Wyndham Milwaukee Center HotelMilwaukee, Wisconsin

The Program Committee is now accepting abstractsfor review for oral and interactive poster presentations.The meeting will take place Thursday, September 9,2004, 6:30-8:30 pm, and Friday, September 10, 2004,8:00 am-4:00 pm at the Wyndham Milwaukee CenterHotel, 139 East Kilbourn Avenue, Milwaukee, WI53202.

The deadline for abstract submission is Friday, July9, 2004, by 3:00 pm EDT. Only electronic submissionsvia the SAEM online abstract submission form atwww.saem.org will be accepted. Acceptance notifica-tions will be sent in late July.

Registration forms are available from Dawn Kawa,Department of Emergency Medicine, Medical Collegeof Wisconsin, 9200 W. Wisconsin Avenue, FEH Room1870, Milwaukee, WI 53226 or dkawa@mcw.edu.

Registration Fees: Faculty--$75; Other health careprofessionals--$40; Fellows/residents/students--NoCharge. Late fee after Wednesday, September 1, 2004:add $10. For questions or additional information, call414-805-6452.