November/December 2023 Common Sense by American Academy of Emergency Medicine

COMMON SENSE VOICE OF THE AMERICAN ACADEMY OF EMERGENCY MEDICINE VOLUME 30, ISSUE 6 NOVEMBER/DECEMBER 2023

The Whole Physician: Restless, Feeling Stuck, Uncomfortable? Maybe It’s Time to Grow Pg 9 President’s Message

The Most Fun I’ve Ever Had in the Emergency Department

Editor’s Message

This Job is Hard

Young Physicians Section

New to the Process

AAEM/RSA President's Message

Corporate Medicine is Not Compatible with Residency

AAEM/RSA Editor's Message:

A Glow-Worm’s Reflection on COVID-19

Table of Contents

COMMONSENSE

Officers President Jonathan S. Jones, MD FAAEM President-Elect Robert Frolichstein, MD FAAEM Secretary-Treasurer L.E. Gomez, MD MBA FAAEM Immediate Past President Lisa A. Moreno, MD MS MSCR FAAEM FIFEM Past Presidents Council Representative Tom Scaletta, MD MAAEM FAAEM Board of Directors Heidi Best, MD FAAEM Laura J. Bontempo, MD MEd FAAEM Kimberly M. Brown, MD MPH FAAEM Phillip A. Dixon, MD MBA MPH FAAEM CHCQMPHYADV Al O. Giwa, LLB MD MBA MBE FAAEM Robert P. Lam, MD FAAEM Bruce Lo, MD MBA RDMS FAAEM Vicki Norton, MD FAAEM Kraftin Schreyer, MD MBA FAAEM YPS Director Fred E. Kency, Jr., MD FAAEM AAEM/RSA President Leah Colucci, MD MS Editor, JEM Ex-Officio Board Member Stephen R. Hayden, MD FAAEM Editor, Common Sense Ex-Officio Board Member Edwin Leap II, MD FAAEM Executive Director Missy Zagroba, CAE Executive Director Emeritus Kay Whalen, MBA CAE Common Sense Editors Mehruba Anwar Parris, MD, Assistant Editor Mel Ebeling, MS3, Resident Editor Stephanie Burmeister, MLIS, Managing Editor Articles appearing in Common Sense are intended for the individual use of AAEM members. Opinions expressed are those of the authors and do not necessarily represent the official views of AAEM or AAEM/RSA. Articles may not be duplicated or distributed without the explicit permission of AAEM. Permission is granted in some instances in the interest of public education. Requests for reprints should be directed to AAEM, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202, Tel: (800) 884-2236, Fax: (414) 276-3349, Email: info@aaem.org

AAEM is a non-profit, professional organization. Our mailing list is private.

COMMON SENSE MAY/JUNE 2023

Foundation Contributions............................................................................................................. 7 PAC Contributions......................................................................................................................... 8 LEAD-EM Contributions................................................................................................................ 8 Academic Affairs Committee: Name, Please?.............................................................................13 Women in Emergency Medicine Section: The Trust Equation....................................................14 Young Physicians Section: New to the Process..........................................................................18 Aging Well in Emergency Medicine Interest Group: Mentorship for the Late Career Physician..................................................................................................................................19 Justice, Equity, Diversity, and Inclusion Section: Adding Insult to Injury: Resident Mistreatment in Emergency Medicine.......................................................................................23 Wellness Committee: #StopTheStigmaEM Month: An Acknowledgment of the Hard Job We Have as Emergency Physicians...............................................................................................25 Women in Emergency Medicine Section: International Medical Students: Equally Prepared for the Field of Emergency Medicine........................................................................................26 Justice, Equity, Diversity, and Inclusion Section: Why Residency Programs Should Expand Their Definition of Underrepresented in Medicine to Include LGBTQ+ Applicants....................27 RSA Editor’s Message: A Glow-Worm’s Reflection on COVID-19................................................29 Leadership Academy: SWOT... or TOWS: The First Leadership Academy Touchback................30 Leadership Spotlight: Run for a Section Council in 2024!............................................................31 Opinion: An Emergency Medicine Physician’s Perspective on Gun Violence and Gun Control.....32 Critical Care Medicine Section: The Disutility of Sodium Bicarbonate in Metabolic Acidosis......34 The Whole Physician: May I Have Your Attention Please?...........................................................37 AAEM/RSA Resident Journal Review: Early Rhythm-Control Versus Rate-Control in Atrial Fibrillation: A Settled Debate?..................................................................................................39 AAEM Job Bank............................................................................................................................43 Upcoming Events.........................................................................................................................45 AAEM ANTITRUST COMPLIANCE PLAN:

As part of AAEM's antitrust compliance plan, we invite all readers of Common Sense to report any AAEM publication or activity which may restrain trade or limit competition. You may confidentially file a report at info@aaem.org or by calling 800-884-aaem.

Mission Statement

The American Academy of Emergency Medicine (AAEM) is the specialty society of emergency medicine. AAEM is a democratic organization committed to the following principles: 1. Every individual, regardless of race, ethnicity, sexual identity or orientation, religion, age, socioeconomic or immigration status, physical or mental disability must have unencumbered access to quality emergency care. 2. The practice of emergency medicine is best conducted by a physician who is board certified or eligible by either the American Board of Emergency Medicine (ABEM) or the American Osteopathic Board of Emergency Medicine (AOBEM). 3. The Academy is committed to the personal and professional well-being of every emergency physician which must include fair and equitable practice environments and due process. 4. The Academy supports residency programs and graduate medical education free of harassment or discrimination, which are essential to the continued enrichment of emergency medicine, and to ensure a high quality of care for the patient. 5. The Academy is committed to providing affordable high quality continuing medical education in emergency medicine for its members. 6. The Academy supports the establishment and recognition of emergency medicine internationally as an independent specialty and is committed to its role in the advancement of emergency medicine worldwide.

Membership Information

Fellow and Full Voting Member (FAAEM): $525* (Must be ABEM or AOBEM certified, or have recertified for 25 years or more in EM or Pediatric EM) Associate: $150 (Limited to graduates of an ACGME or AOA approved emergency medicine program within their first year out of residency) or $250 (Limited to graduates of an ACGME or AOA approved emergency medicine program more than one year out of residency) Fellow-in-Training Member: $75 (Must be graduates of an ACGME or AOA approved emergency medicine program and be enrolled in a fellowship) Emeritus Member: $250 (Please visit www.aaem.org for special eligibility criteria) International Member: $150 (Non-voting status) Resident Member: $60 (voting in AAEM/RSA elections only) Transitional Member: $60 (voting in AAEM/RSA elections only) International Resident Member: $30 (voting in AAEM/RSA elections only) Student Member: $40 (voting in AAEM/RSA elections only) International Student Member: $30 (voting in AAEM/RSA elections only) Pay dues online at www.aaem.org or send check or money order to: AAEM, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202 Tel: (800) 884-2236, Fax: (414) 276-3349, Email: info@aaem.org

AAEM-1023-364

VOICE OF THE AMERICAN ACADEMY OF EMERGENCY MEDICINE

VOLUME 30, ISSUE 6

NOVEMBER/DECEMBER 2023

COMMONSENSE Featured Articles

President’s Message: The Most Fun I’ve Ever Had in the Emergency Department

When and where was the most fun you’ve ever had in the ED? OK, Dr. Jones admits that “fun” may not be the most accurate word to use…instead you can use rewarding, satisfying, enthralling, sincere, humbling, or maybe even exciting? But, whichever word you choose, Dr. Jones answers the question himself.

Editor’s Message: This Job is Hard

The Whole Physician: Restless, Feeling Stuck, Uncomfortable? Maybe It’s Time to Grow

CAL/AAEM: The House of Medicine Has Already Burned, How to Recover After the Fire

One question you probably have not asked yourself lately is what can a lobster teach me? And, I can nearly guarantee that you definitely have never asked yourself, an emergency physician, what lessons can I learn from bison? In this article, the Whole Physician doctors tell you—it’s more than you think!

Financial Wellness: What is a Financial Plan?

Can you see your financial goals clearly like you can see a flag on a mountaintop? Yes? Okay, good. Now, the hard question. Do you know how to get there? In this issue’s Financial Wellness column, Dr. McNeil walks you through the steps you need to take to develop and maintain a financial plan to achieve your financial goals.

16 Common Sense Editor, Dr. Leap, admits that the last weeks at work for him have been very busy. Some it is the same, standard stuff like congestions and fevers, but other cases are new, different, and increasingly prevalent. But, no matter the problem, the person expected to solve it is us—the emergency physician.

Advice to Senior EM Residents (Actually, All Residents and Fellows)

In this article, Dr. Garmel shares observations and actions that can increase the likelihood of success and happiness not only for EM residents, but for all those at any stage in their medical training. A commitment to lifelong learning is not only a universal concept, but it has never been more imperative.

Emergency medicine physicians need to realize one thing—we are not trying to put out a fire at the house of medicine. It has already burned down. But, we can rebuild and history will judge us by how we recover. And California is no stranger to rebuilding after fires so join CAL/AAEM and Take Medicine Back on February 10 for our Advocacy Summit.

AAEM/RSA President’s Message: Corporate Medicine is Not Compatible with Residency

If Dr. Colucci was a money-hungry CEO at a for profit system, the first thing she would do is staff her ED with as many midlevels and residents as she could. Next, she’d find a tired, burnt-out physician to borrow their medical license while they staff the patients of all her PAs and residents. Are you raising your eyebrows at CEO Colucci? You should be, says Dr. Colucci.

COMMON SENSE NOVEMBER/DECEMBER 2023

The Most Fun I’ve Ever Had in the Emergency Department

AAEM PRESIDENT’S MESSAGE

Jonathan S. Jones, MD FAAEM

nstead of discussing Academy business, challenges to our specialty, or new initiatives, I want to ask a question paired with my answer. When and where was the most fun you’ve ever had in the ED? Fun may not be the most accurate word to use, but it fits the sentence. Replace “fun” with any word you would rather use such as rewarding, satisfying, enthralling, sincere, humbling, exciting, or whichever word you need most. I recently asked this question of myself, not because I was bored, but because I was stressed out, burned out, tired, and perhaps a bit depressed. I (mostly) love emergency medicine and the Academy, but that does not mean everything is roses. The field of emergency medicine is continuing to face challenges and while addressing these is satisfying, it is a long process. The hardest working physicians in the world are still being taken advantage of by corporate entities. And other professional societies and organizations are actively fighting to keep it this way. The Academy’s latest setback—we are now searching for a new lobbying firm since our current firm dropped us at the request of one of their other clients—The Emergency Department Practice Management Association (EDPMA). Ha! So much for pleasantries and working together. But more on that later. Yes, I am frustrated and stressed out. And while I haven’t run my theory past a psychiatrist yet, it seems that when frustrated and stressed out, sometimes instead of doubling down on the problem, it’s best to focus on the positives and change the topic. So, I asked the question to myself, “What is the most fun I’ve ever had in the emergency department?” I must have an answer to this, or maybe many answers. After all, I’ve been telling students

What is the most fun I’ve ever had in the emergency department?’ I must have an answer to this…I’ve been telling students and residents for years that emergency medicine is fun. Was I lying

this whole time?

and residents for years that emergency medicine is fun. Was I lying this whole time? No, no I was not. Nearly immediately I knew I had not been lying because when I started to think about the most fun I’d had in the ED, it was difficult to narrow down to just one time. There were too many great experiences. Sure, I momentarily thought of some of those incredible chief complaints, those “accidents” which result in some foreign body, and the bizarre logic which at times has brought patients to the ED. No, these are all superficial. I next thought of rewarding instead of fun experiences. Those patients who truly came in with minutes or hours to live and who days or weeks later were successfully discharged home. The hemiplegic and aphasic patient who hours later was talking normally. The CHF or COPD patient breathing 40 times a minute who was successfully not intubated. The patient leaving the ED happy after a fairly benign visit but with a new understanding of their disease because no one else had ever explained it properly. Those babies I have delivered and handed to their new mother to hug for the first time ever.

I even thought of a patient that I treated on a recent holiday. After a good meal, he clutched his chest and collapsed. CPR was started and still in progress when he arrived at the ED. We obtained ROSC but with further investigation it was obvious that he had suffered a fatal injury. While his heart was still beating and his blood pressure was maintained, I knew that I could not save his life. I engaged with multiple specialists who agreed. But this did not end my care for him. In caring for him, I needed to care for his family. We had extensive discussions. It was hard for me and I can only imagine how it was for them. This was a horrible and completely unexpected occurrence. However, I think that I was able to help him and his family. There were questions and answers, hugging and crying, grief and resolution. As they left, we shook hands. When he passed, I know he felt no pain, dyspnea, or suffering of any kind. I think that I provided some comfort. I hope I did. This was certainly not fun, nor good, nor rewarding. I’m not truly sure what word I would use to describe how I felt. I do know that this encounter came to mind when I was trying to think of the good things about emergency medicine. Bad things happen in this world and death is ultimately

COMMON SENSE NOVEMBER/DECEMBER 2023

AAEM PRESIDENT’S MESSAGE

unavoidable, but that doesn’t mean we can’t help, at least a little. We each have had so many experiences in the ED. Some negative for sure, but many more positive, at least in some way. So many thoughts were coming into my head about things I liked about EM, I was struggling with a way to wrap them all together. And I instantly knew the answer to that…the Mississippi Delta. A little over a year ago, I started doing some Locum Tenens work in the Mississippi Delta. In case you’re not familiar with this part of the country, I’ll provide a bit of background. First, the Mississippi Delta is not actually a river delta. Yeah, when I first moved to Mississippi, I figured the Delta was in the south, you know, where the river deposits sediment in the Gulf of Mexico. No, not at all, that is the Mississippi River Delta and is actually in Louisiana. The Mississippi Delta is the northwestern part of Mississippi and includes small parts of Arkansas and Louisiana. Its soil is incredibly fertile and its people are incredibly poor. In fact, it is often ranked as the poorest part of the country. And while there are lists of areas of this country with the poorest people, I’ve had a harder time finding lists of areas with the nicest people. But what I have discovered is that the Mississippi Delta would rank very high on that list as well. I remember one particular shift from not that very long ago. I nearly always work night shifts at this location and started my 12-hour shift at 7pm. Walking in, I already smiled a bit to myself as I received a warm welcome from the nursing staff. We all know that any professional is only as good as their team, and I had a good team this night. And they were happy to see me. I’m not sure how good I am, but they couldn’t stop talking about how happy they were that I was on shift tonight. It may have something to do with the fact that it is rare to have a true board-certified emergency physician on shift. Regardless of the reason, it sure is nice to walk into a shift with smiling faces.

were a few sign-outs, mainly waiting on labs or CT results. The hospital was once fairly large, and physically still is, but now only has a grand total of twelve inpatient med/surg beds, plus a fairly busy OB service. We typically have no specialty services but have a friendly hospitalist and OB/GYN. There is also one incredibly nice general surgeon, but only if it happens to be Wednesday. It was Monday. Patients here are different than at the large urban centers where I’ve typically worked. Yes, it’s a generalization, but they just seem more straight-forward. Not their medical cases, but their histories. They work hard and when something doesn’t feel right, they simply tell you. There are almost no ulterior motives. I see more people wanting to get a doctor’s note stating it is OK for them to return to work than I do asking for work excuses. They don’t come in with a diagnosis and treatment plan in mind, they simply explain their symptoms and ask my opinion. They are nearly universally thankful for whatever advice and treatment I can provide.

This was a typical Monday night shift, busy but not unmanageable. In a 12 hour shift at this hospital, I’ve seen anywhere from 14 to 40 patients. I’ve admitted anywhere from zero to five, but I often end up transferring more patients than I admit given the lack of local services. As most of us know, the most frustrating part is nearly always arranging the transfer. Luckily, there is an excellent pediatric hospital about an hour away which has never refused any of my patients. Similarly, transferring acute strokes, trauma, or STEMIs is handled very well and is quite easy. Everything else…not so much. This evening I had a patient with a Type A aortic dissection. Amazingly the patient was fairly stable and controlling his blood pressure and pain was the easy part. Finding a place to transfer him was the hard part. We called dozens of larger hospitals and were repeatedly told their thoracic surgeon was out or they didn’t have beds. Previously, in situations like this, I would end up contacting the state’s only >>

I walked outside as I try to do this time of the morning to watch a Mississippi Delta sunrise. It was quiet, a little bit cool, and beautiful.

I thought about people and the good they can do.

This hospital ED has ten rooms and usually at the start of night shift they are full or nearly full, just as they were on this evening. There

COMMON SENSE NOVEMBER/DECEMBER 2023

AAEM PRESIDENT’S MESSAGE

academic medical center for assistance. However, Mississippi’s only academic center has been so bogged down with bureaucratic processes that they basically don’t accept any transfers. The system in place even precludes me from merely speaking with a specialist. While I was treating other patients, one nurse kept trying. She finally told me that she found an accepting physician and hospital. I was thrilled… until she told me that it was in St. Louis, Missouri. Needless to say, that was not really great news. I called back one of the large community hospitals which had initially refused the patient due to capacity issues. I ended up speaking to the thoracic surgeon and explained the situation. He agreed that transfer to Missouri was not appropriate. He also agreed that bureaucracy should not cost a patient his life—exceptions must be able to be made. He accepted the patient and even thanked me for calling back and not transferring this patient to St. Louis. All of this at about 3am. The other interaction which made an impression on me was an elderly woman with a small bowel obstruction secondary to an incarcerated hernia. She was accompanied by her even more elderly husband and despite her condition, they were both incredibly happy and thankful for anything we could do. I was able to get her accepted at a hospital a little over an hour away, not too bad really. But I thought more about her as a person and her husband. Neither of them drove and they had no other local family. I knew we technically didn’t have surgery at this time, but I called the local surgeon despite this. His reply was fairly close to, “No, no, don’t send her to Oxford. Keep her here and I’ll take care of her. I know I’m not on call but I don’t care. Call me 24/7/365, sometimes I can’t help, but if I can help a patient here, then I will, that’s why I’m here.”

By now it was a little before 6:00am and the ED was empty. I walked outside as I try to do this time of the morning to watch a Mississippi Delta sunrise. It was quiet, a little bit cool, and beautiful. I thought about people and the good they can do. I thought about the hard-working patients I treated over the night. I thought about the two doctors who technically had no obligation to work or to help a patient but who also had absolutely no hesitation in doing the right thing. Doing a little Locums work can be refreshing. For all its challenges, rural America is amazing. Systems and bureaucracy can be frustrating, but people are good. While Robert Johnson may have had to sell his soul about half a mile down the road in this Mississippi Delta town for success, all I had to do was show up, smile, and try. Rural EM is rewarding, refreshing, fun, and even has better sunrises. It can renew your excitement in practicing medicine. The Academy even has a Rural Medicine Interest Group and Locums Tenens Section to help you along the way. Consider giving it a try. (Scan the codes below for more information.) As we begin a new year, I urge you to think about the great things you have done and the many patients you have helped. And maybe even consider a change of scenery, I know one place where you would be welcome and rewarded.

Rural Medicine Interest Group aaem.org/get-involved/interest-groups

Locum Tenens Section aaem.org/get-involved/ections/lt

COMMON SENSE NOVEMBER/DECEMBER 2023

This Job is Hard

EDITOR’S MESSAGE

Edwin Leap II, MD FAAEM

he last couple of weeks at work have been very busy. It seems as if I’m running from the time I walk into the ED until I walk out the door. Some of it is the standard, seasonal cold and flu dance. “I’ve got this congestion in my chest!” “My baby has had a fever since this morning.” The usual things we learn to navigate over the course of a career without so much as batting an eye.

Against the backdrop of this, our physicians are simply overwhelmed and exhausted. More than ever in my career I hear good doctors trying to make plans to leave the field. But I know them. I know that it isn’t the challenge of sickness or the stress of managing grave injuries. Those are the things, those are the sufferings, that attracted us in the first place, as we sorted through career choices and skipped right over easy, stressfree lives and plunged into human misery and circadian devastation.

Some of it, though, is different. It’s the sort of thing I’ve watched growing over the last thirty years. It’s people living longer but still being very sick. It’s the devastation of self-destructive behaviors, in particular the use of fentanyl and methamphetamine. I spend way more time dealing with sepsis and endocarditis from IV drug abuse than ever in my career.

What makes our colleagues aspire to leave the field is the fact that we are treated dismissively and that the systems in place are inadequate. It’s that those in charge do not demonstrate that they truly care about the precious resource of their professional staff or about the consequences of the shortages and overwhelming volumes we manage to bear, no matter how unsafe or demoralizing. Worse, our non-clinical leaders and managers really don’t have any good ideas on how to make it better. (Other than Friday afternoon candy or pizza distributions.)

Things are also different because of the collapse of anything like a mental health system, coupled with an odd and dramatic surge in assorted psychiatric diagnoses which leave us holding the mentally ill for days to weeks. Not to mention the shocking explosion of suicidal thoughts and behaviors in children. Furthermore, it seems that healthcare black hole eventually pulls everything into the emergency department with irresistible gravity. In part due to poverty, in part due to the lack of available primary care and in part because of a combination of marketing and our own successes, people understand that the ED is the place to go to get care, day or night, all week long. No matter the problem, large or small, it ends up on our doorstep. Where, ironically, we seem to have fewer resources. Despite hospitals marketing their cancer centers or weight loss programs, their new cath labs or robotic surgery centers, a lot of what we need day to day is MIA. I often struggle to find specialists for my patients need, or even ambulances or helicopters to transfer them to those specialists. Whether we’re looking for an ED bed for a patient languishing in the waiting room, or an inpatient bed for someone with a bowel obstruction, the inn is full. And of course, all of the inns are full. Our hallways daily resemble disaster zones, with the wounded and moaning, bleeding and apneic lying in stretchers wherever we can squeeze them into a spot against the wall.

What else drives physicians away? It’s unfair contracts and compensation. It’s physicians afraid to speak their opinions because they might be fired. It’s unsafe staffing practices. It’s non-compete clauses that can stunt or wreck careers. It’s residency closures leaving young physicians stranded. It’s the belief that any kind of degree is the same as a medical degree. In point of fact, the real wonder, the real miracle of American healthcare is that despite all of this, emergency physicians keep going back to work, easing suffering, saving lives, and generally making emergency departments function. (The other miracle is that good care keeps happening without daily carnage…testament to the dedication of the staff at every level.) >>

No matter the problem, large or small, it ends up on our doorstep. Where, ironically, we seem to have fewer resources. COMMON SENSE NOVEMBER/DECEMBER 2023

EDITOR’S MESSAGE

The thing is, there is always hope. I’ve lived in South Carolina for most of my career. Our state motto is “Dum Spiro Spero,” or for the Latin impaired, “While I breathe, I hope.” There’s hope because we are simply hard-working people who dig our heals in and do the right thing. There’s hope because some patients, and some administrators, really do recognize the importance of what we do. And there’s hope because very smart people, very passionate people, are constantly advocating for our specialty. I have been a professional writer for almost as long as I’ve been a physician. I’m good at making people laugh and say, “See! That’s what I’m talking about!” I find delight in hearing a reader say, “I thought I was the only one who felt that way.” My job is to find an issue and shine a light on it and sometimes hold it under a magnifying glass; until it starts to smoke or bursts into flames.

This is a hard job. But AAEM is trying to make it better.

But now that I’m an editor for this publication, and honored to be affiliated with the members of this organization, I can say that I get to work with physicians who do more than tell us what the problems are. They do more than talk the talk. These people walk the walk. They do the hard work of finding answers to the problems that the rest of us find vexing but feel powerless to fix. And they do it always with an eye to compassion and fairness for all. There isn’t space here to list the amazing people from AAEM and the projects they undertake. However, that’s what this organization, and to a lesser extent this publication, exist to do. All you need is to read through and be encouraged by the work being done in the name of the specialty. No, rather, in the name of every single person who does the hard work of practicing emergency medicine.

COMMON SENSE NOVEMBER/DECEMBER 2023

This is a hard job. But AAEM is trying to make it better. It’s hard to make it easier, at least in terms of the clinical and societal challenges we face. However, our advocates in this excellent organization can at least do everything in their power to see that while we do the difficult things, we are treated with respect, treated fairly, are secure in our jobs, and are compensated appropriately. So please spread the word! Share articles with non-member friends! And encourage them to join for the sake of the specialty and our patients. And continue to consider sending your own thoughts to me for publication. I have some fascinating articles, by wonderful writers, in the pipeline. So stay tuned. And keep the faith!

AAEM Foundation Contributors – Thank You!

AAEM established its Foundation for the purposes of (1) studying and providing education relating to the access and availability of emergency medical care and (2) defending the rights of patients to receive such care and emergency physicians to provide such care. The latter purpose may include providing financial support for litigation to further these objectives. The Foundation will limit financial support to cases involving physician practice rights and cases involving a broad public interest. Contributions to the Foundation are tax deductible. Levels of recognition to those who donate to the AAEM Foundation have been established. The information below includes a list of the different levels of contributions. The Foundation would like to thank the individuals below who contributed from 1/1/2023 to 11/1/2023.

Contributions $1000 and above Algis J. Baliunas, MD FAAEM Babak Khazaeni, MD FAAEM Brian T. Hall, MD FAAEM David W. Lawhorn, MD MAAEM Jonathan S. Jones, MD FAAEM Kathryn Getzewich, MD FAAEM Laura J. Bontempo, MD MEd FAAEM Mark Reiter, MD MBA MAAEM FAAEM Oscar A. Marcilla, MD FAAEM Thomas R. Tobin, MD MBA FAAEM

Contributions $500-$999 Fred Earl Kency, Jr., MD FAAEM Jeffery M. Pinnow, MD FAAEM FACEP Pedro I. Perez, MD FAAEM Robert A. Frolichstein, MD FAAEM Ronald T. Genova, MD Timothy J. Titchner, MD FAAEM

Contributions $250-$499 Andy Walker, MD MAAEM Bradley Houts, MD FAAEM Daniel N. Seitz, MD FAAEM David Thomas Williams, MD FAAEM Eric D. Lucas, MD FAAEM Floyd W. Hartsell, MD FAAEM Jeffrey J. Thompson, MD FAAEM Kenneth Scott Hickey, MD FAAEM FACEP Laura Richey, MD FAAEM Leonard A. Yontz, MD FAAEM Luke C. Saski, MD FAAEM Marc R. Houston, DO FAAEM Mark A. Antonacci, MD FAAEM Mark A. Foppe, DO FAAEM FACOEP Mark A. Newberry, DO, FAAEM, FPD-AEMUS Ming-Jay Jeffrey Wu, MD FAAEM Nayla M. Delgado Torres, FAAEM

Piotr Jurgielewicz, MD Robert J. Feldman, MD FAAEM Shane Coughlin, MD Travis J. Maiers, MD FAAEM

Contributions $100-$249 Adam C. Benzing, MD MPH Alexander Tsukerman, MD FAAEM Andrew Thomas Larkin, DO FAAEM Anisha Malhotra, MD FAAEM Ann Loudermilk, MD FAAEM Arnold Feltoon, MD FAAEM Barry N. Heller, MD FAAEM Brian J. Browne, MD FAAEM Brian J. Cutcliffe, MD FAAEM Brian R. Potts, MD MBA FAAEM Bruce E. Lohman, MD FAAEM Bryan Knoedler, MD Catherine V. Perry, MD FAAEM Chaiya Laoteppitaks, MD FAAEM D. Scott Moore, MS DO FAAEM Daniel R. Saltzman David R. Steinbruner, MD FAAEM David Wang, MD FAAEM Denis J. Dollard, MD FAAEM Donald L. Slack, MD FAAEM Douglas P. Slabaugh, DO FAAEM Gary M. Gaddis, MD PhD MAAEM FAAEM FIFEM H. Samuel Ko, MD MBA FAAEM Irene Tien, MD FAAEM Jason M. Driggs, MD FAAEM Jeffrey A. Rey, MD FAAEM Jenna Otter, MD FAAEM Jessica Moore, MD Jonathon D. Palmer, MD FAAEM Jorge L. Infante, MD FAAEM Julianne Wysocki Broadwater, DO FAAEM Kathleen Hayward, MD FAAEM

Katrina Green, MD FAAEM Katrina Kissman, MD FAAEM Marc D. Squillante, DO FAAEM Michael S. Westrol, MD FAAEM Nancy Conroy, MD FAAEM Neeharika Bhatnagar, MD FAAEM Patrick B. Hinfey, MD FAAEM Patrick G. Woods, MD FAAEM Paul W. Gabriel, MD FAAEM Philip Beattie, MD FAAEM Renee Marie Nilan, MD FAAEM Riley MW Williams, MD MBA Robert Boyd Tober, MD FAAEM Rohan Janwadkar, MD Roland S. Waguespack III, MD MBA FAAEM Ryan S. DesCamp, MD MPH Sameer D. Mistry, MD MBA CPE FAAEM Stephen H. Andersen, MD FAAEM Tim J. Carr, FAAEM Timothy J. Durkin, DO FAAEM CAQSM William E. Franklin, DO MBA FAAEM Yeshvant Talati, MD

Contributions up to $99 Alexander J. Yeats, Jr., MD FAAEM Alexander S. Maybury, MD FAAEM Amie Rose, MD Andrew J. Bleinberger, MD Benson Yeh, MD FAAEM Brian Gacioch, FAAEM Caitlin E. Sandman, DO FAAEM Christopher Laugier David C. Crutchfield, MD FAAEM Edward T. Grove, MD FAAEM MSPH Eric M. Rudnick, MD FAAEM Ernest H. Leber Jr., MD FAAEM Erol Kohli, MD MPH FAAEM Everett T. Fuller, MD FAAEM

Gregory H. Whitcher, MD Heather Madler James P. Alva, MD FAAEM James R. Gardner, FAAEM Jason J. Morris, DO FAAEM Jeffrey B. Thompson, MD MBA FAAEM Joanne Williams, MD MAAEM FAAEM Jonathan Y. Lee, MD FAAEM Jose G. Zavaleta, MD Joseph M. Reardon, MD MPH FAAEM Kelly Dougherty, MD Kenneth T. Larsen, Jr., MD FAAEM Kevin C. Reed, MD FAAEM Kevin McGurk, MD FAAEM Linda Sanders, MD FAAEM Marianne Haughey, MD FAAEM Matthew Mosko Mass, DO Megan Crossman, MD FAAEM Merlin T. Curry, MD Michael Lajeunesse, MD Michael Timothy Schultz, MD FAAEM Michael West Monica Johnson, MD FACEP FAAEM Neal Handly, MD Om Pathak, DO Peter H. Hibberd, MD FACEP FAAEM Peter M.C. DeBlieux, MD FAAEM Peter Stueve, DO Robert M. Dumas, MD Saba A. Rizvi, MD FAAEM Sachin J. Shah, MD FAAEM Samuel M. Morris, MD Scott Beaudoin, MD FAAEM Stacy G. Hooks, MD Tabitha Williams, FAAEM Virgle O. Herrin Jr., MD FAAEM

COMMON SENSE NOVEMBER/DECEMBER 2023

AAEM PAC Contributors – Thank You! AAEM PAC is the political action committee of the American Academy of Emergency Medicine. Through AAEM PAC, the Academy is able to support legislation and effect change on behalf of its members and with consideration to their unique concerns. Our dedicated efforts will help to improve the overall quality of health care in our country and to improve the lot of all emergency physicians. All contributions are voluntary and the suggested amount of contribution is only a suggestion. The amount given by the contributor, or the refusal to give, will not benefit or disadvantage the person being solicited. Levels of recognition to those who donate to the AAEM PAC have been established. The information below includes a list of the different levels of contributions. The PAC would like to thank the individuals below who contributed from 1/1/2023 to 11/1/2023.

Contributions $500-$999

Contributions $100-$249

Mark S. Penner, DO FAAEM Ronald T. Genova, MD

Alexander S. Maybury, MD FAAEM Alexander Tsukerman, MD FAAEM Brian J. Cutcliffe, MD FAAEM Brian R. Potts, MD MBA FAAEM Bruce E. Lohman, MD FAAEM Catherine V. Perry, MD FAAEM David W. Lawhorn, MD MAAEM Donald L. Slack, MD FAAEM Garrett Sterling, MD FAAEM Gary M. Gaddis, MD PhD MAAEM FAAEM FIFEM Jeffrey A. Rey, MD FAAEM Jeffrey B. Thompson, MD MBA FAAEM Jeffrey J. Thompson, MD FAAEM Joseph M. Reardon, MD MPH FAAEM Julianne Wysocki Broadwater, DO FAAEM Katrina Green, MD FAAEM

Contributions $250-$499 Andy Walker, MD MAAEM Bradley Houts, MD FAAEM Fred Earl Kency, Jr., MD FAAEM Joseph T. Bleier, MD FAAEM Luke C. Saski, MD FAAEM Mark A. Antonacci, MD FAAEM Mark A. Foppe, DO FAAEM FACOEP Michael L. Martino, MD FAAEM Paul W. Gabriel, MD FAAEM Thomas B. Ramirez, MD FAAEM Tim J. Carr, FAAEM Travis J. Maiers, MD FAAEM

Nicole M. Braxley, MD MPH FAAEM Patrick B. Hinfey, MD FAAEM Philip Beattie, MD FAAEM R. Lee Chilton III, MD FAAEM Raviraj J. Patel, MD FAAEM Riley MW Williams, MD MBA Robert Boyd Tober, MD FAAEM Robert M. Esposito, DO FAAEM Stewart Sanford, MD FAAEM William E. Franklin, DO MBA FAAEM

Contributions up to $99 Alex Kaplan, MD FAAEM Amie Rose, MD Andrew J. Bleinberger, MD Brice Guy, DO Chaiya Laoteppitaks, MD FAAEM David L. Sincavage, Jr., MD FAAEM

David R. Steinbruner, MD FAAEM Eric M. Rudnick, MD FAAEM Erol Kohli, MD MPH FAAEM James R. Gardner, FAAEM Jason J. Morris, DO FAAEM Kevin C. Reed, MD FAAEM Kevin McGurk, MD FAAEM Laura M. Mory, MD FAAEM Linda Sanders, MD FAAEM Marc D. Squillante, DO FAAEM Merlin T. Curry, MD Om Pathak, DO Peter H. Hibberd, MD FACEP FAAEM Peter Stueve, DO Ruth P. Crider, MD FAAEM Tabitha Williams, FAAEM Virgle O. Herrin Jr., MD FAAEM

LEAD-EM Contributors – Thank You! The AAEM Institute for Leadership, Education & Advancement in the Development of Emergency Medicine, Inc. (LEAD-EM) was established after the tragic and unexpected death of AAEM president, Dr. Kevin G. Rodgers. The Kevin G. Rodgers Fund and the Institute will LEAD-EM just like Dr. Rodgers did. The funds will support important projects such as development of leadership qualities, and clinical and operational knowledge of emergency physicians with a view toward improving and advancing the quality of medical care in emergency medicine, and public health, safety and well-being overall. LEAD-EM would like to thank the individuals below who contributed from 1/1/2023 to 11/1/2023.

Contributions $1000 and above

Mark A. Foppe, DO FAAEM FACOEP Mary Ann H. Trephan, MD FAAEM

Jonathan S. Jones, MD FAAEM

Contributions $100-$249

Contributions $500-$999 Fred Earl Kency, Jr., MD FAAEM Jeffery M. Pinnow, MD FAAEM FACEP Mark Reiter, MD MBA MAAEM FAAEM

Contributions $250-$499 Dale S. Birenbaum, MD FAAEM David W. Lawhorn, MD MAAEM Leonard A. Yontz, MD FAAEM Luke C. Saski, MD FAAEM Mark A. Antonacci, MD FAAEM

COMMON SENSE NOVEMBER/DECEMBER 2023

Alexander S. Maybury, MD FAAEM Ann Loudermilk, MD FAAEM Brian R. Potts, MD MBA FAAEM Catherine V. Perry, MD FAAEM Christopher Kang, MD FAAEM David R. Steinbruner, MD FAAEM Edward T. Grove, MD FAAEM MSPH Gary M. Gaddis, MD PhD MAAEM FAAEM FIFEM Joseph M. Reardon, MD MPH FAAEM Julianne Wysocki Broadwater, DO FAAEM

Kathleen Hayward, MD FAAEM Kevin C. Reed, MD FAAEM Michael S. Westrol, MD FAAEM Paul W. Gabriel, MD FAAEM Roland S. Waguespack III, MD MBA FAAEM

Contributions up to $99 Alicia J. Starr, DO Erol Kohli, MD MPH FAAEM Jose G. Zavaleta, MD Marc D. Squillante, DO FAAEM Merlin T. Curry, MD Om Pathak, DO Richard G. Foutch, DO FAAEM

Samantha Abramovich Samuel M. Morris, MD Virgle O. Herrin Jr., MD FAAEM

Contributions up to $99 Alicia J. Starr, DO Erol Kohli, MD MPH FAAEM Jose G. Zavaleta, MD Marc D. Squillante, DO FAAEM Om Pathak, DO Richard G. Foutch, DO FAAEM Samantha Abramovich Samuel M. Morris, MD Virgle O. Herrin Jr., MD FAAEM

THE WHOLE PHYSICIAN

Restless, Feeling Stuck, Uncomfortable? Maybe It’s Time to Grow Amanda Dinsmore, MD FAAEM, Laura Cazier, MD FAAEM, and Kendra Morrison, DO

Lobsters Grow?” It pointed out that lobsters are soft creatures within a hard shell that does not expand. For it to grow, it has to undergo the perilous and exhausting process of dissolving the old shell (leaving it very vulnerable to predators) and growing a new one—only to have to do it multiple times throughout its life.

any of us are not huge fans of negative emotions. We have the mistaken perfectionistic idea that doing life “right” means feeling continuous peace, love, and joy. So when uncomfortable feelings like boredom, angst, dread, and the like come up, many of us shove them down, engage in toxic positivity, or distract from them with things like food, alcohol, shopping, or whatever your numbing agent of choice is. But what if “negative emotions” are just signals, signs that it’s time to evaluate our course, nothing to avoid or stress about? Let’s discuss.

The stimulus to grow is the pressure, the discomfort, the feeling of confinement. It finally becomes uncomfortable enough to do something. Rather than popping a valium, drinking a bottle of wine, using comfort food, zoning out with TV, or whatever else we do to avoid our negative emotions, Rabbi Twerski says “times of stress are also times that are signals for growth. If we use adversity properly, we can grow through adversity.” Discomfort Research Research from Wooley and Fishbach theorized that if people were encouraged to see discomfort as a sign of progress, it could be motivating.3 Traditionally, we often see it as the opposite: a sign that there’s a problem.

Motivational Triad In 2006, Drs. Douglas Lisle and Alan Goldhamer published a book called The Pleasure There were five experiments Trap.1 In it, they theorize why with a total of about 2,000 we are driven to do the things adults. They tested this prewe do like overeat, overdrink, diction across various uncomover shop, over scroll, and fortable scenarios: taking imother addictive behaviors. A provisation classes to increase The stimulus to grow is the pressure, the discomfort, key concept they put forward is self-confidence, engaging in the feeling of confinement. It finally becomes the Motivational Triad. It says expressive writing to process uncomfortable enough to do something. that for survival, we are driven difficult emotions, becoming by three key components of informed about the COVID-19 our evolutionary brain: seek health crisis, opening oneself pleasure, avoid pain, and be efficient. That served us fantastically for sur- to opposing political viewpoints, and learning about gun violence. One vival purposes for thousands of years, and it explains why we seem so group was encouraged to seek discomfort and see it as personal develdetermined sometimes to avoid discomfort. Our brains are just trying to opment. They were told feeling uncomfortable meant that the experiment keep us safe. But safe doesn’t mean fulfilled. Safe doesn’t mean content. was working. The other group was given generic instructions to go learn In modern times, the majority of us can do things like listen to podcasts something. Those encouraged to seek discomfort as a signal of selfand have our basic needs met. The motivational triad, while great for growth were more motivated, engaged, persistent, and open to important survival, can interfere with our growth and fulfillment as human beings or information, even when it was hard to hear.4 living authentically. Kira Newman summarizes this research and says, “All this research goes to show that we might be judging normal human experiences like Lessons from a Lobster nervousness, stress, and discomfort too harshly. While our inclination There’s a video on YouTube from Rabbi Abraham Twerski, a psychiatrist might be to avoid them, they seem to be part of becoming better who specialized in addiction.2 He described waiting in a dentist’s office, people and living a rich life.”5 thumbing through a magazine, and seeing an article titled “How do

COMMON SENSE NOVEMBER/DECEMBER 2023

THE WHOLE PHYSICIAN

Lessons from Bison If you’re thinking, “My goodness, this Common Sense piece is strangely dense with animal references,” you’re right. But for a good reason. Zoology was the pre-med track at my [AD] college, so I can’t help it.

your mind. So little by little—progress rather than perfection here—don’t put it down, put it away. And while you’re checking your email, delete, archive, or respond. As long as you’re going in the right direction it’s inevitable you’ll get there.

One fascinating thing that bison have learned about an impending storm is that, as opposed to other animals that attempt to flee or huddle together waiting, it is much quicker to turn, face the storm, and walk through it.6

Better Finances Why aren’t more people on top of their financial health? Because it seems painful. But again, not knowing weighs heavily. Getting over the initial hurdle of handling your finances leads to a huge reduction in stress.

There are several benefits to turning toward discomfort. James Killian, LPC, is a therapist who mentions several:7 Reduced Procrastination Procrastination is simply avoidance. But it isn’t without dread. So there’s the discomfort of doing the task and there’s the discomfort of having the task looming. Only one moves you through it. Exercise and Healthier Nutrition Starting to exercise and eat more nutritiously can certainly be uncomfortable. But, as in the studies mentioned before, if you can reframe the discomfort as working for your benefit, you can vastly improve your overall health. “Comfort” food, if it’s harming your health, isn’t that comforting after all.

Better Relationships

Killian says, “If there is one similarity among people with poor boundaries, it’s that they can’t stand being uncomfortable. This aversion leads to poor boundaries in relationships which ultimately creates symptoms of depression, anxiety, loneliness, and more. Master your ability to experience discomfort and watch your satisfaction with your relationships will improve drastically.”

Mental Mastery A stellar way for emergency physicians to be uncomfortable on purpose is meditation. There are misconceptions about meditation. One is that you must have zero thoughts. That’s not exactly true. It’s the act of metacognition, or put another way, noticing your thoughts when they arise without judgment, letting them pass, and recentering again. Practicing meditation can be a great way to start to master your mind. Bonus: it can just be for a couple of minutes a day. New Experiences Tackling a new skill, language, or instrument can be uncomfortable. Many of us Type-A folks don’t like the discomfort of doing something at a novice level. But that’s what it takes to develop new brain connections and skills. Leaning into this discomfort brings new richness and layers to your life. Declutter and Inbox Zero Clutter and non-dispositioned emails, for example, are a result of procrastination. And it’s not without consequence—it weighs on

COMMON SENSE NOVEMBER/DECEMBER 2023

Final Thought We think that by avoiding having a hard conversation, developing a new skill, starting a side hustle, leaving a toxic relationship, or procrastinating doing the hard task we need to do, somehow we are avoiding the discomfort. However, if you’ve ever felt “stuck” you know that you’re not avoiding discomfort at all. It’s miserable in “stuck”—that’s why we self-medicate while we’re in it. By setting our lives up to avoid uncomfortable emotions like failure, embarrassment, conflict, and struggle, we end up getting…wait for it…other uncomfortable emotions like boredom, restlessness, complacency, and not truly knowing what you’re capable of.

George Addair said, “Everything you’ve ever wanted is sitting on the other side of fear.” Maybe everything you’ve ever wanted is sitting on the other side of discomfort. Discomfort may merely be a necessary signal that it’s time to grow. Editor’s Note: “The Whole Physician” article for the September/October issue of Common Sense was omitted from publication. We apologize for this error. You can find the September/October “The Whole Physician” article on page 37 of this issue. Countinued on page 12 >>

FINANCIAL WELLNESS

What is a Financial Plan? Chris McNeil, MD

ast time, we discussed a broad range of financial considerations at different stages of a career. This month, I decided to write about the next most logical step you need to take to tackle any of those broad topics, and that is to obtain or develop a financial plan. We should begin by describing the process. A financial plan is a comprehensive and structured strategy designed to serve as a road map to help achieve financial goals and objectives. A well-crafted plan may cover all aspects of finances including budgeting, savings, investments, debt management, insurance, retirement planning, college planning, current and future tax situations, business succession planning for business owners, risk mitigation, legacy and estate planning, and charitable giving. It provides a framework for making informed decisions about income, expenses, and investments to ensure long-term financial stability and security. For example, how will a larger down payment on a house or purchasing a more expensive house affect a person’s long-term financial goals? A financial plan is a living document—it should be reviewed regularly and adjusted based on how our life circumstances change over time. Operationally, a very large document is produced with many pages of spreadsheets, future tax projections, cash flow diagrams, etc., that ultimately give a guideline on how much we need to save, in what types of accounts we should save, and how long we need to save to meet our goals. These calculations also include assumptions of rates of investment return and forward-looking inflation expectations. And even more importantly, they help determine the most efficient withdrawal strategy once we fully retire and need to live off our assets. Plans need to be reviewed regularly to adjust for any changes in goals (I have more children than expected), life situations (divorce), changes in investment returns (downturn in the economy), or inflation expectations. The most difficult part of developing a financial plan is determining your goals. I recommend spending the most time on goal development. There is no reason to develop a plan if you don’t know the goal. The plan itself is just a bunch of numbers and math—the heart of the plan is your goals. And goals can change throughout your life. Most people haven’t really thought through this before. I see it all too often. Let me give you a few examples of what to think about to develop your goals.

Do you want to retire, particularly at a younger age than most? When do you want to retire? What do you want to do in retirement (spend most of your time at home with grandchildren or travel the world to hard-to-reach places)? Do you want to work full-time until you retire, or might you want to work part-time for a while before retiring? What do you want your career to look like? Might you change careers and have a different income? Have you considered planning for a sabbatical year mid-career? How much travel do you want to be able to do in retirement? Do you want to learn a new craft? Do you want your kids to attend a private college or state university? Do you want to pay for all of your kids’ college, or will they pay by taking out loans? If you have a spouse, what do they think about these goals?

When you set your goals, it is okay to dream big; the planning process will let you know if it is a realistic goal. Once you’ve thought about your goals and are ready to begin saving, you might choose to have a financial professional assist you in this process. If you choose to meet with a financial professional to have a plan created for you, you will want to be prepared for the meetings. Certainly, it’s important to have your basic financial information available. More importantly, you should consider what you want this financial professional to do for you. After all, you are hiring them to work for you. >>

COMMON SENSE NOVEMBER/DECEMBER 2023

FINANCIAL WELLNESS

If you are a DIY investor and you do your own financial planning and investment management—awesome! Kudos for having the desire and interest to educate yourself and take control of your financial future. I work with many physicians who manage their own investments and are very successful in doing so. However, what I see more commonly are physicians (in all stages of their careers) who are more concerned about recovering from night shifts, spending time with their families, and keeping up to date with their CME. These colleagues do not have the desire, interest, or time to pay attention to the markets, economy, and their investment accounts. Unfortunately, many of them felt like they should do it on their own because that was the word on the street. Sometimes they end up in a situation in which they can’t pay their taxes (IRS problems), didn’t save appropriately for college and now have extra fees and taxes, or started the process and then “ran out of time” falling way behind on their retirement savings. Instead, I find myself helping people like this who tried to do it themselves and made mistakes with their back-door Roth contributions, took inappropriate 529 withdrawals, and procrastinated getting help for far too long. The examples are numerous.

A financial plan is a living document— it should be reviewed regularly and adjusted based on how our life circumstances change over time. Choosing a financial professional is a personal decision, but I can tell you what I was looking for when I hired one many years ago. It goes without saying that I wanted to hire someone trustworthy who was a fiduciary and was a certified financial planner (CFP®). I was also looking for someone who was part of a team, did not treat me as if I was another customer in line, and would function as my family’s CFO (The CEO role was already taken by my wife). I wanted someone who took my thoughts seriously, could understand my perspective, and who wasn’t going to try to “sell me something.” Ultimately, you should interview multiple financial planners and “kick their tires” a bit. Make sure you find someone who makes you feel comfortable. It’s actually not much different than interviewing new primary care physicians for yourself. Find a good fit. Finally, I want to address a potentially polarizing topic for some. We are in a safe space here, right? I firmly believe that everyone needs a financial plan. This next sentence may sound like a sacrilegious comment from someone who works in the finance world—I also do not think everyone needs to work with a financial professional or have someone else manage their investments during every stage of their lives. However, having lived in both worlds, I have an interesting perspective, so allow me to briefly explain.

There is no reason to develop a plan if you don’t know the goal. The plan itself is just a bunch of numbers and math—the heart of the plan is your goals.

Many of us have been told by countless Dr. Blogs over the last 15 years that financial management is something we can do for ourselves, and we shouldn’t need to pay someone else to do this for us. After all, we are smart, educated people. I agree with this to a certain point. What I want to draw awareness to is the disastrous unintended consequences of this advice that I have seen firsthand.

Thus, having been on both sides, here is my takeaway. We are all smart, educated people who are capable of creating a financial plan and investment strategy for ourselves. However, if you do not have the interest, time, or desire to do it on your own, please let your CPA do your taxes, your lawn service mow your yard, and your financial planner manage your financial plan. The worst-case scenario is the IRS is not after you, your lawn looks superb, and you are on track to hit your financial goals. The next topic will be dealing with aging parents. See you next time.

THE WHOLE PHYSICIAN

Countinued from page 10

References 1. Douglas J. Lisle, Alan Goldhamer. The Pleasure Trap: Mastering the Hidden Force that Undermines Health & Happiness. March 30, 2006 by Healthy Living Publications 2. How do Lobsters grow? https://www.youtube.com/ watch?si=f9C4BNSSG2JouOWp&v=dcUAIpZrwog&feature=youtu. be&themeRefresh=1 3. Woolley, K., & Fishbach, A. (2022). Motivating Personal Growth by Seeking Discomfort. Psychological Science, 33(4), 510–523. https://doi. org/10.1177/09567976211044685

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4. https://www.psychologytoday.com/us/blog/imperfect-spirituality/202206/ what-we-gain-being-uncomfortable 5. https://greatergood.berkeley.edu/article/item/embracing_discomfort_can_ help_you_grow 6. https://bisoncentral.com/the-bison-advantage/ 7. https://arcadiancounseling.com/9-reasons-get-comfortable-withdiscomfort/

Name, Please?

ACADEMIC AFFAIRS COMMITTEE

Mary Claire O’Brien, MD FAAEM

ears ago, we had a resident who grew up in a part of the country that is well known for being casual. He was affable, intelligent, eager, and self-confident. He struggled a bit as an intern and so was particularly proud to introduce himself as an “upper year” the following July. I think it went to his head! Suddenly he started calling me by my first name. “Mary Claire, can I tell you about a patient?” I almost had a seizure. I was practicing medicine before this kid was born! “Sure, Doctor Rogers,” I sputtered. Introductions can be challenging for young physicians. They want to be sociable but need to be recognized as the team leaders. They are afraid people will think they are arrogant. Female physicians have the added legacy of the gender divide in clinical practice—although half of practicing emergency physicians are women, female nurses still outnumber male nurses nine to one. “Nurse, would you get me a urinal please?” “Of course, sir. I’m Dr. O’Brien. I’ll be happy to get you a urinal.” Here are a few tips… Introduce yourself using your title. Just do it! “Hello, I’m Dr. Walker, the attending physician.” If the nurse responds, “Hi, I’m Bethany. What’s your first name?” Respond, “It’s Keisha, but at work I prefer to be called Dr. Walker.” You do not need to apologize or explain. It’s your name! Adding the qualifier “at work” is collegial, it means that if you met one another outside the hospital, you would be fine with her calling you by your first name.

In front of patients, always call other doctors by their title.

You are a junior attending and some of the house staff are older than you are. Address the residents by their title. “Dr. Hassan, did you order that repeat lactate?” Never mind that Dr. Hassan has only been a doctor for three months and she is still not even sure you are speaking to her when you say “Doctor.” If Dr. Hassan says, “Oh, call me Nikki,” answer, “Thank you, Nikki. I’m Dr. Jones.” At what age do you start calling a patient “Mr.” or

“Ms.”? When they are old enough to vote. If a young patient corrects you, “Hey, man, I’m Hector,” don’t say, “Whassup, Hector? I’m Tyler.” Say: “Nice to meet you, Hector. I’m Dr. Williams.” What do you do if an elderly patient only tells you their first name? “Hello, Doctor, I’m Bessie.” Whether she is married or single, in the South we respond, “Hey, Miss Bessie. Nice to meet you.” The best approach is to ask an older patient, “What would you prefer me to call you?” How do you introduce yourself to another doctor? That depends. 1. You already know they are a doctor. “Hello, Dr. Smith? I am Mary Claire O’Brien, the attending physician.” As a courtesy, you give your first name to another physician. She may respond, “Hello, Dr. O’Brien,” or “Hello, Mary Claire. Please call me Elizabeth.” 2. You didn’t know that they are a doctor, and they correct you. Awkward turtle! Don’t flinch. It happens. “Hello, Ms. Smith? I am Dr. O’Brien. Oh? It’s Dr. Smith? Nice to meet you, Dr. Smith. I am Mary Claire O’Brien, the attending physician.”

As a general rule, call other doctors by their title until invited to do otherwise. In front of patients, always call other doctors by their title. This goes for residents (your own and consultants) as well as for non-physician doctors (e.g., doctors of pharmacy, physical therapy, or nursing). Address your PhD patients as “Doctor” unless they instruct you to do otherwise—they earned it! How is a PA introduced? When speaking privately, you address one another as “Fred” and “Ricky.” When you introduce him to patients, he is “PA Mertz.” In summary, decide in advance how you would like to be addressed. Ask others how they would like to be addressed. Clear communication is essential to collegial relationships. Do not hesitate to use your professional title if that is your preference.

COMMON SENSE NOVEMBER/DECEMBER 2023

The Trust Equation

WOMEN IN EMERGENCY MEDICINE SECTION

Molly Estes, MD FAAEM FACEP

as anyone noticed that our departments are getting busier? That we are being pushed to see more patients faster? To minimize workups while also ensuring our patients understand there are massive delays in further outpatient follow up because our clinics are similarly overrun? That we have less and less time per patient? Now let me pose this question: have you heard about medical gaslighting? In an article published by the New York Times in July 2022, this phenomenon is defined as “having one’s concerns dismissed by medical professionals.”1 There seems to be a growing and pervasive perspective from the patient population that doctors and the medical system are out to get them. Or if at least not directly and intentionally harm them, to discredit and ignore, to provide unequal services, to let insurance and business drive decisions instead of expertise and professionalism. No longer is it accepted that to wear the white coat makes you knowledgeable and reliable; instead, it is a symbol of distrust and suspicion.

Trustworthiness = (Credibility x Reliability x Intimacy) ÷ Self-Orientation (Interest)2 The numerator of the equation is composed of three elements: credibility, reliability, and intimacy. Credibility is one’s knowledge and abilities to perform a task. Reliability on the other hand is your consistency in performing, in completing assignments and keeping your word. Lastly, intimacy is your connection with others, how you invite others to confide in you. Now all three of these principles are countered by self-orientation, or sometimes called self-interest. This is the idea that your actions and decisions are not self-serving but rather for the benefit of someone else.

If we are fighting to restore our patients’ trust in us, then we need to look at ways to improve our performance in these different areas. Some of these are more modifiable than others. For example, I don’t know how to make myself more credible to my patients beyond what my medical degree, board certification, and years of experience can do. But reliability, well now there is something I can do better on. How many times have you NO LONGER IS IT told a patient you’ll be back to discuss their results with ACCEPTED THAT TO them, then sent the nurse to do it instead so you could go see someone else? Something as simple as saying, “your WEAR THE WHITE nurse or I will discuss your results” instead immediately COAT MAKES YOU changes your patient’s perception of the end of their encounter. Or printing the work note instead of them needKNOWLEDGEABLE AND ing to ask for it again, remembering to send a prescription RELIABLE; INSTEAD, for the over-the-counter medication when asked—all of these show that our patients can rely on us more. IT IS A SYMBOL

OF DISTRUST AND SUSPICION.

The problem fundamentally becomes this: in a world of less time and more suspicion, how do we get our patients to trust us? Because this is the true fundamental principle behind ensuring patients not only follow our treatment recommendations but can leave our departments feeling heard and reassured. So now that I have you feeling all warm and fuzzy, let’s introduce a new concept: the Trust Equation. Introduced by Charles H. Green to the business world in 2000,3 the trust equation breaks trust down into four principles: 14

COMMON SENSE NOVEMBER/DECEMBER 2023

Intimacy is a difficult one. Things are certainly better than the truly dark days of COVID when we couldn’t even physically go into every room, or tried to communicate through windows and sign language. But there is still a breakdown in the personal connection our patients feel with us. Sitting in a chair in the hallway, next to the perhaps loud, smelly, belligerent, or otherwise most distressing patient in the department does not create an environment of comfort where someone can feel as if they can confide in us. Being repeatedly interrupted during a conversation to sign an EKG, respond to a radio call, or correct an order, also doesn’t. Again, some of these things are completely out of our control, but there are actions we can take. If possible, designate the slightly quieter hallway chair as your “sharing results and disposition” chair. Going back to basics and sitting down next to the patient creates more connection. One of my colleagues stores a tripod folding chair in the corner of our workroom just to >>

WOMEN IN EMERGENCY MEDICINE SECTION

Trust has been broken between our patients and us. Not always, not with everyone, but enough that we can see and feel it. And it is our responsibility to see how we might begin to fix it. Slowly, day-by-day, patient-by-patient.

ensure he can do this simple thing. Asking if the patient understands and has any questions, and then truly caring about their answer, can achieve more connection. We need to find methods to move away from the “treat ‘em and street ‘em” nature our busy departments have come to. Finally, that last little pesky detail, the self-orientation part of it all. This is the most influential factor in the equation as it is the sole denominator. All of our efforts in the other three areas are nothing if we fail to address self-orientation. This comes down to finding ways to reassure our patients that we are not simply trying to make it through our workday, or making excuses for why things took so long or can’t be done today. This involves us being human with our patients. To offer the truth that the lab is short staffed, a CT scanner is down, that you just got six trauma patients. And immediately after that, thanking them for their patience and telling them that you are here to help them now. And again, truly meaning it. Setting expectations early on can help mediate perception References 1. Caron, Christina. “Feeling Dismissed? How to Spot ‘medical Gaslighting’ and What to Do about It.” The New York Times, The New York Times, 29 July 2022, www.nytimes.com/2022/07/29/well/mind/medical-gaslighting. html. 2. “The Trust Equation: A Simple Summary.” The World of Work Project, 28 July 2021, worldofwork.io/2019/07/the-trust-equation/.

that someone is being overlooked or forgotten. “You might not see me again for a couple hours, but I am constantly following up on all your results and testing. If you need more medicine to help with your symptoms, please tell your nurse and I will make sure to order it.” Or whatever version of a similar sentiment might feel right to you to employ. Trust has been broken between our patients and us. Not always, not with everyone, but enough that we can see and feel it. And it is our responsibility to see how we might begin to fix it. Slowly, day-by-day, patient-by-patient. There is another half to trust, the patients’ side. We can only hope that they are willing to extend us grace and compassion as we find ourselves operating in a broken, over-stressed, under-financed system attempting to help whomever we can, whenever we can, wherever we can. Editor’s Note: Article derived from the “EM Over Easy” podcast episode “Trust Equation.” Author’s credit to Andrew Little, DO, Drew Kalnow, DO, and Tiffany Proffitt, MD. 3. “Understanding the Trust Equation: Trusted Advisor.” Trusted Advisor Associates - Training, Workshops, Trust Education, 27 Apr. 2020, trustedadvisor.com/why-trust-matters/understanding-trust/understandingthe-trust-equation. 4. Wai, Faye. “Trust Equation: How to Assess Trust.” Jostle Blog, blog.jostle. me/blog/trust-equation. Accessed 29 Sept. 2023.

COMMON SENSE NOVEMBER/DECEMBER 2023

Advice to Senior EM Residents (Actually, All Residents and Fellows) Gus M. Garmel, MD FAAEM FACEP

o Senior Residents in EM:

Congratulations on making it to your final year of training! This is certain to be an exciting time. It will also be challenging and stressful. Never forget that the work you do is important to the lives, health, and wellness of so many people, their families, and friends. There is a great deal to learn and to crystallize during your final year of training, whether you are in your third or fourth year of residency, or in fellowship. To assist with your transition, I share several observations and describe five actions that can increase the likelihood of your success and happiness. There will also be a tremendous amount of information to process after graduating, some of which I address. As much of this information is universal, it will have value for medical students, interns, residents at any stage of training in any discipline, fellows, and junior faculty. A commitment to lifelong learning in healthcare (especially in EM) has never been more imperative.

that influence your career. For EM to thrive while continuing to provide the best possible care to anyone, at any time, for any reason, hospital and political leaders (with our input and assistance) must focus their efforts on improving key elements of EM practice. 2 These include, but are not limited to, soaring boarding rates,3,4 lengthy admission times, limited bed availability (in the ED and the hospital), problems impacting ED throughput and efficiency, lack of specialty consultant access, widespread and escalating workplace violence,5,6 increasing mental and substance use-related illnesses, and the difficulties our patients face scheduling necessary follow-up care. Interhospital relationships and relations with EM and non-EM colleagues, as well as respect for EM within GIVEN HOW hospital systems, are fundamental to perCHANGES IN THE sonal and overall success. These relationEM LANDSCAPE ARE ships must be valued and reinforced. When they are strong, individual EPs and EDs tend CONTINUOUS AND to receive greater support from the medical RAPID, MY FIRST and administrative staff. Our patients, their SUGGESTION IS TO families, and members of the community also have an important role. They should be BE PRESENT AND encouraged to share their stories with adPAY ATTENTION. ministrators and politicians, through letters, phone calls, surveys, or on social media.

Given how changes in the EM landscape are continuous and rapid, my first suggestion is to be present and pay attention. Be present in your interactions with your patients and colleagues. Pay attention to the political climate in EM (at national and state levels), to organizations in EM, and to the business of EM (nationally and locally). Give intentional attention to these areas, in addition to scientific advances in our field. This knowledge will prove relevant throughout your career, which, despite its challenges, will hopefully be productive, lengthy, and satisfying. As the safety net for healthcare and for the public, the demands placed on EM and EPs are difficult to meet. Attention to these challenges increased during the pandemic, when the general public and public officials correctly labeled first responders and emergency personnel as “heroes.” Sadly, much of this favorable attention has waned. However, an important opportunity remains for us to rebrand ourselves and our specialty, of which we should take advantage.1 Given EM’s intersection with so many stakeholders, my next suggestion is to become familiar with the individuals and organizations

COMMON SENSE NOVEMBER/DECEMBER 2023

ADVICE TO SENIOR EM RESIDENTS (ACTUALLY, ALL RESIDENTS AND FELLOWS)

There is no weakness in focusing on your own health and wellness, seeking advice, understanding your limitations, and being dedicated to continuous learning and improvement. Additional internal and external influences to give careful attention include inherent nuances of the ED and the hospital where you work. Clinical and administrative support in EM and in the ED, as well as diversity, equity, and fairness, are significant factors to consider during your transition to attending staff. Hiring and promotion practices, advancement opportunities, objective pay, equitable scheduling, staffing, and assignments or responsibilities that include activities unrelated to direct patient care greatly impact your work environment. Changes in the leadership of EDs, ED groups, and hospitals relate to income and job security, which may produce stress and anxiety, which likely impact career satisfaction. The corporatization of EM, hospital and/or group consolidations, healthcare worker burnout and attrition, and workplace safety are getting national notice.7,8 Fortunately for EM, national fee structures have started to increase, and surprise billing has received political attention as well. My hope is that attention to these vital aspects of EM will translate to enhanced healthcare outcomes for patients, consistently excellent patient care experiences in better ED environments, upgraded safety for everyone in the ED, increased job security, more EM positions, and improved career satisfaction. Given my expertise with and passion for career planning9 and mentoring,10,11 I’d like to share five major areas which often create problems for graduates in their new positions. Consider these during your final year of training and strive to further develop them. Seek guidance in these areas while EM faculty at your program are available to assist you. 1. Conflict Resolution/Conflict Management (i.e., interpersonal relations)

How well or how poorly do you handle a disagreement or conflict with a patient, family member, colleague, consultant, tech, nurse, director, or administrator? How does your ability to handle conflict impact your responsibility serving as your patients’ advocate? How skillfully can you handle a disagreement with a colleague or consultant that directly relates to patient care (for example, disagreeing with their clinical recommendation after you’ve sought their opinion)? How healthy are your pre-existing relationships, and how well do you establish new (first-time) relationships, particularly during an intense or time-sensitive moment? How well do you negotiate? How well do you “play” with others in the healthcare “sandbox”? Communication is key, including verbal and nonverbal (such as body posture, positioning, and gaze), writing or messaging, active listening, and collaborating. EM textbook chapters on conflict resolution and conflict management offer additional background and much-needed tools.12,13

including the logistics surrounding their delivery and statistical analysis. It is also important to identify which other metrics are measured at your new facility and ED. Commonly collected, monitored, and used metrics include physician time to patient, time to disposition, patient complaints, number of return visits (even though this may be positive due to detailed discharge instructions that are followed), number of labs or imaging tests ordered, number and “appropriateness” of consultants called (which may have nothing to do with your clinical skills), and number or percentage of patients admitted. To some extent, these metrics relate to efficiency and throughput, as does the metric of how frequently the ED “backs up” when you are working (often a gestalt made by others, such as a charge nurse, which may also have nothing to do with your skills). These metrics and perceptions answer the question, “How smoothly does the ED run while you are working?” Hospital administrators and ED leaders pay attention to this and to any patterns that emerge. 3. Billing/Coding/Documentation

These may not matter to you now (or ever), although they should since they matter to people at your new hospital. Despite their significance, billing, coding, and documentation are frequently not taught well during residency (possibly because many faculty aren’t comfortable with this knowledge or aren’t coding and billing themselves).15 I encourage everyone to become familiar with and learn the electronic medical record (EMR) system at your new hospital prior to providing direct patient care. Within the EMR, it is critical to accurately record and correctly document those things you are doing and the care you are providing, including necessary interpretations. This generates revenue for your group, for your hospital, and possibly for you (directly or indirectly). Furthermore, appropriate documentation, coding, and billing should improve your job security. If your group depends on revenue generated from patient care that is reimbursed as the result of documentation, coding, and billing, why wouldn’t they also pay attention to individual metrics related to reimbursement? This is especially true if an ED is losing money, or if you are an outlier compared to your colleagues with respect to billing (and generating revenue). Despite these pressures, do not bill for things you haven’t done, which is illegal. Nor should you perform procedures or order tests that are unnecessary for extra revenue, which is unethical. Granted, documentation, coding, and billing are difficult topics. Gain as much exposure as possible during your training and prior to your new position. I also strongly recommend meeting with the billing company at your new position early on (preferably before you start) and more than once, soliciting feedback about how you are doing and how you can improve.16

2. Efficiency

4. Wellness, Especially Resilience

Metrics matter to many people, particularly administrators and hospital leaders.14 I strongly recommend that you find out which tool and/or company is used for patient satisfaction surveys as early as possible,

How are you taking care of your own health and needs? How well are you sleeping? How often are you pursuing hobbies and relationships Countinued on page 22 >>

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YOUNG PHYSICIANS SECTION

New to the Process Jack Allan, MD

ost of my audience has or will someday have the experience of becoming a new attending. That has been the goal since before medical school even began. I’m certainly not novel in digesting this transition, but have come to recognize some important sources of career motivation after assuming this new title. Residency was a unique experience with a host of challenges. As a resident, you are heavily focused on rapid clinical growth, meeting expectations of your on-shift attendings and program leadership, as well as gaining the confidence to soon be an independent practitioner. While the transition to becoming a new attending was both exciting and nerve-wracking, it came with several significant changes in mindset. I’ve long been told that practicing medicine will involve daily learning, and that is certainly true. However, attending-hood has come with other, less anticipated changes. Most specifically for me, the time and autonomy to reflect on the department I function within. As a resident, it is easy to bypass process inefficiencies or even potential patient safety concerns, accepting these problems to be for the department leadership to solve. However, as an attending, I have not only found a greater sense of pride and commitment toward my department, but a growing sense of ownership and capacity to effect changes.

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“AS A NEW ATTENDING, I THOUGHT FOR A FLEETING MOMENT THAT I HAD ARRIVED AT THE DESTINATION. BUT THAT’S NOT THE CASE. THERE IS ALWAYS MORE WORK TO BE DONE.”

I would argue that process improvement is as much a part of my job today as is providing clinical care. In fact, creating more efficient, safer patient care spaces is vital to my clinical practice. I have found myself increasingly interested in studying the ways in which my department functions, learning from other departments that might do things differently, and then using this understanding to create changes. It doesn’t always go as planned, but that’s part of the process. Studying medicine has long felt like a journey to a destination, becoming the attending in the room. As a new attending, I thought for a fleeting moment that I had arrived at the destination. But that’s not the case. There is always more work to be done: processes that can be made more efficient, new treatment algorithms that promote patient safety, or integration of new ideas that make for a better, safer department. As a community of new attendings, our careers have only just begun. We can look forward to becoming problem solvers and growing into leaders that will continue to push our departments to always improve.

AGING WELL IN EMERGENCY MEDICINE INTEREST GROUP

Mentorship for the Late Career Physician Joshua Silverberg, MD and Peter Gruber, MD

entorship does not come with an expiration date. It can be a helpful tool for those in the twilight of their medical careers just as it is for those at the onset of a career. For the physician starting out, mentorship has been shown to lead to an enriched career with increased connections, improved productivity, and career satisfaction.1 Whether mentorship comes as a guiding hand leading us through transitions or a trusted voice counseling us on life after medicine, it can serve to help us make thoughtful decisions. We would like to make the argument that having a The same guiding hand during the community tail end of our careers can be of great benefit. that we build

to support each other throughout our careers can help us navigate our lives post-career.

Retirement may be the finish line, but how we spend the last portion of our careers can define our legacies. Often this is a time defined by impactful transitions and lateral moves toward roles in which we have less experience. Working in the emergency room is often physically draining, defined by hours spent on our feet and performing rigorous procedures. That is one of the reasons it is common for ER physicians to shift toward academics and administrative tasks in place of clinical roles as we age. But determining which niche fits both our unique experiences and personalities to create the most fulfilling transition can be very dauting without the guidance of a mentor. A well thought out plan including the mentorship of seasoned and retired physician colleagues can help make the transition from full time to part time work or retirement more rewarding and less of a shock.2-4 The closer we find ourselves to retirement, the more we may find ourselves thinking about what we’ve accomplished and our ongoing projects. As many of us have turned to mentors during mid-career for advice on accepting increased responsibilities and creating new roles, there is need for continuing those established mentor relationships when it comes to the handing off of responsibilities at the end of our careers. As ER doctors, we are concerned on a daily basis about handing off responsibilities at sign out and know all too well how many things can go awry at the end of a clinical shift. On a larger scale, knowing which pitfalls to avoid and how best to select replacements will help with the ease of transition and even help preserve the integrity of our projects and studies. Advice

from someone who has successfully been through this transition can also extend to how to properly teach our replacements to take up the mantle. In a 2015 article for Annals of Emergency Medicine titled “To Retire or Not: That is the Question,” Dr. Mark L. DeBard details the difficulties of navigating end of career choices without the guidance of a mentor.5 As an aging physician in a young specialty, he had no one to seek advice from. Questions as simple as how to time retirement can become overwhelming when there is no one who can give guidance. It is important to note that physician retirement planning and timing is not only beneficial to the physician but to patient safety and the healthcare system. 47% of active physicians in 2021 in the U.S. were over 55 years old and over 40% of physicians will be more than 65 years old in the next decade.6-8 Emergency medicine, while being a younger specialty, has many physicians joining this age group. Now is the time to learn how to counsel each other in how to approach these life events and avoid interruptions in care as we move away from the important work we do. Much of the guidance we receive throughout our careers from mentors relates to financial savings. The setting up of savings plans, retirement funds, and even passive income opportunities is a popular topic among mentors and mentees in the medical community. There is often, however, a dearth of guidance when it comes to the disbursement of the funds and transitioning expenses to meet the new requirements of retirement. We spend our whole careers saving for retirement, it would be a shame to go into retirement uninformed about our options. Those who have retired before us can help guide us from their vantage point. Countinued on page 24 >>

Mentorship does not come with an expiration date. COMMON SENSE NOVEMBER/DECEMBER 2023

CAL/AAEM

The House of Medicine Has Already Burned, How to Recover After the Fire Jesse Borke, MD FAAEM and Mitchell J. Li, MD FAAEM

e have all seen (and felt) the burnout statistics, the match results, emergency physicians (EPs) having less time at the bedside with our patients, the exponential increases in corporate-managed emergency departments (EDs), the inadequate staffing, the increasing inappropriate use non-physician practitioners, the charts showing EPs being paid less each and every passing year in terms of real wages, and perhaps saddest and most telling of all is that the showing that the public has lost faith in American physicians on an unprecedented scale.1 We need to wake up and realize that we are not trying to put out a fire. The house has already burned. History will judge us by how we recover. California is no stranger to rebuilding after fires. This February 10, join us in Palm Springs California where CAL/AAEM and Take Medicine Back will be hosting the first annual advocacy summit to take the profession of medicine back from corporate practice.2

Understand that the fire was lit by greed, and some of the arsonists lived in our house. The greed began with the contract management groups described in “The Rape of Emergency Medicine” by Dr. James Keany and which went nuclear with the entry of private equity into medicine.1,3 Greed by lay entities, greed by private equity, and yes, greed by complacent and complicit physicians, is why the physician-patient relationship has been severely eroded in American medicine. The corporate practice of medicine (CPOM) kills patients and ruins lives. The statistics don’t lie. The solution to greed is simple: cut them off from the money supply they are addicted to. One way to do this is to enforce existing prohibitions on CPOM right now, while strengthening, honing, and expanding them. Ask yourself, “why is there no corporate practice of law?” The answer is simple because lawyers have defended the attorney-client relationship. Physicians have failed to hold the physician-patient relationship in the same esteem. There is a growing recognition, especially among younger physicians, that this may be our last chance to learn from the mistakes of our predecessors. There is no path forward for EPs without enforcing the ban on the corporate practice of medicine.

Here are three things you can do right now to begin taking the profession back for yourself:

1 Unionize—before it’s too late. Recognize that you are labor. If you work in a hospital, you are likely not a partner, and do not have meaningful ownership. As labor, you should use the tools available—unionization. Corporations depend on “friendly physician” arrangements to circumvent laws prohibiting the corporate practice of medicine. Meaningful ownership requires not only fiscal equity, but political equity—the ability to meaningfully affect your work environment. Being a partner has little to do with receiving a K-1 or a tiny little equity bonus check at the end of the year after the people who are actually in control take their giant salaries and slices of the pie.3 The large group you work for may advertise that they are “physician owned” and that you are a “partner” but let’s put aside the ego and get real for a minute. Being a partner means that you, the doctors seeing patients and generating revenue at the bedside, control staffing of both physicians and non-physicians, control how many patients you see in a shift, the patient-physician relationship, and exactly what is billed in your name and under your license. Do you control those things? Can you change them whenever needed? A partner in fact absolutely can. That power is what makes them a partner. You are labor and labor is a cost on the profit and loss, right below disposable rubber gloves and syringes. The people that actually own your practice regard you as a cost to be managed and controlled. Cheaper rubber gloves and cheaper “providers” both increase their profits in the exact same way. Several recent articles have compared EPs to another group of highly skilled laborers, national football league (NFL) players, and the comparison is not flattering. Dr. Bob McNamara noted over a decade ago that “Ed Garvey, the former executive director of the NFL Players Association, spoke at one of the first AAEM annual meetings, and basically said this situation makes us dumber than pro athletes…Think about it; [would a pro athlete] ever say to his agent, ‘Negotiate my salary with the team, >>

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CAL/AAEM

and then keep that secret from me and pay me whatever you want.’ It’s enough to make you question whether NFL players or physicians are the ones with the head trauma.”4 As of 2019, 7.2% of the 938,156 physicians actively practicing in the United States were physician union members. That’s 67,673 doctors.5 Physician unions are spreading like wildfire, so this is likely an underestimation. It is estimated that greater than one in twelve physicians in the U.S. are currently unionized right now, today. Check out existing unions like the Union of American Physicians and Dentists (UAPD), Service Employees International Union (SEIU), Doctors Council, and groups around the country that have recently unionized, such as Allina Health (MN and WI),6 Ascension St. John (MI),7 LA County Physicians (CA),8 Providence Medford Medical Center (OR),9 NYC Health + Hospitals (NY),10 and Legacy Health (OR).11 Even if you are a partner in name only (PINO), but not a partner in fact, you can likely still join a union. This is because the National Labor Relations Board may consider physicians without control over any real decisions, or who are unable to work elsewhere, etc., to be misclassified as “owners” or as independent contractors, and to fit the definition of an employee.

you read ACEP’s communications, it appears that their energy is spent disproportionately concealing their complicity in the rise of corporatized medicine and lobbying against Medicare cuts on behalf of ACEP’s corporate special interests. The ironic truth is that if the bans on CPOM were enforced, it would free up more money for rank-and-file EPs than all the Medicare cuts in the world. Join AAEM and get active in your state 3 AAEM chapter.

Support the AAEM-PG lawsuit to set precedent to end the corporate practice of medicine.12 Support Dr. Ming Lin in his fight for due process for all emergency physicians against corporate giants Teamhealth and Peacehealth.13 Unlike ACEP, AAEM actually has a long track record of success.14 Join and get active in Take Medicine Back.15 Federal legislators and regulators have been increasingly engaging with AAEM and TMB at the decision-making table. Unlike ACEP, TMB has a proven track record of success: take Medicine Back participated as the only invited emergency medicine group to speak in front of the Federal Trade Commission (FTC) on the firsthand effects of consolidation in healthcare and has been engaging legislators on both sides of the aisle.

Ask yourself, “why is there no corporate practice of law?” The answer is simple because lawyers have defended the attorneyclient relationship. Physicians have failed to hold the physicianpatient relationship in the same esteem. and support the groups that support 2 Join you and your patients.

As much as we wish we could, the sad truth is that we cannot count on legacy organized medicine such as the American Medical Association (AMA) or the American College of Emergency Physicians (ACEP) to save our profession. AMA recently failed to adopt a resolution authored by AAEM Board Member and Take Medicine Back advisory board member, Dr. Vicki Norton, to seek federal legislation to prohibit CPOM. It is well known at this point that ACEP leadership pioneered the exploitative contract management group (CMG) model, and that subsequent leadership has perpetuated it. Recently, under substantial pressure, ACEP has attempted to rehabilitate their public image, and adopted a strong statement opposing the corporate practice of medicine introduced by Dr. McNamara. Unfortunately, until they start working in earnest toward enforcing prohibitions on CPOM, due process, and billing transparency, their statements should be regarded as nothing more than empty gestures and hot air. As Texas Governor Ann Richards once said, “You can put lipstick on a hog and call it Monique, but it is still a pig.” If

Join CAL/AAEM and Take Medicine Back on February 10, 2024, in Palm Springs, CA in person for our Advocacy Summit.

Please join CAL/AAEM and Take Medicine Back, along with our growing political coalition including U.S. Representative Katie Porter, Senator Elizabeth Warren, Arizona Representative and candidate for U.S. Congress, Amish Shah, MD. We will be joined by Hayden Rooke-Ley, JD, an author of the “New England Journal of Medicine” article, “A Doctrine in Name Only: Strengthening Prohibitions on the Corporate Practice of Medicine,” and many incredible physician-speakers from both AAEM and Take Medicine Back. Finally, always keep perspective. What you do is critically important. We are agents of the greater good for all mankind. I will leave you with this quote from Dr. Edwin Leap, “The good is the return to normality of the injured. The good is the rescue from the peril of the dying. The good is to sometimes share in their suffering by being uncomfortable. The good is sometimes to take a chance and do what seems right, even though no one else will try.”

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References 1. Do You Trust the Medical Profession? - The New York Times - https:// www.nytimes.com/2018/01/23/upshot/do-you-trust-the-medical-profession. html 2. https://www.aaem.org/event/calaaem-advocacy-summit-2024/ 3. James Keaney, MD, The Rape of Emergency Medicine 4. Viewpoint: ‘EPs are Dumber than Pro Athletes’ : Emergency Medicine News - https://journals.lww.com/em-news/fulltext/2013/03000/ viewpoint___eps_are_dumber_than_pro_athletes_.14.aspx 5. Advocacy Issue Brief: Collective bargaining for physicians and physiciansin-training - https://www.ama-assn.org/system/files/advocacy-issue-briefphysician-unions.pdf 6. Allina Health clinicians to form largest group of unionized physicians in US private sector - https://www.fiercehealthcare.com/providers/allina-healthclinicians-form-largest-group-unionized-physicians-us-private-sector 7. Contracted emergency doctors at Ascension St. John vote to unionize https://www.detroitnews.com/story/news/local/wayne-county/2023/07/13/ contracted-emergency-doctors-at-ascension-st-john-hospital-vote-tounionize-nlrb/70409871007/

8. L.A. County doctors and dentists give green light for possible strike https://www.latimes.com/california/story/2023-11-22/l-a-county-doctorsand-dentists-give-green-light-for-possible-strike 9. Providence ER providers vote unanimously to unionize | Local&State | rv-times.com - https://www.rv-times.com/localstate/providence-erworkers-vote-unanimously-to-unionize/article_e29615ce-e3f7-11ed-824977a07fcfed82.html 10. Montefiore Medical Center residents, fellows win right to unionize | Modern Healthcare - https://www.modernhealthcare.com/labor/montefioremedical-center-win-vote-unionize-nlrb-seiu-ny 11. Legacy Health physicians vote to unionize - https://www. beckershospitalreview.com/hr/legacy-health-physicians-vote-to-unionize. html 12. Envision Lawsuit – AAEM - https://www.aaem.org/envision-lawsuit/ 13. Stand with Dr. Ming Lin: A Fight for Due Process and Patient-Centered Care – AAEM - https://www.aaem.org/stand-with-dr-ming-lin/ 14. https://apps.aaem.org/UserFiles/Jan-Feb14HighlightsofAAEMsLegalAdvo cacyforEPs.pdf 15. Take Medicine Back - https://www.takemedicineback.org/

ADVICE TO SENIOR EM RESIDENTS (ACTUALLY, ALL RESIDENTS AND FELLOWS)

Countinued from page 17

outside of work?17 Are you exercising regularly and eating well? Are you smoking, drinking, or relying on medications to help you deal with stress, anxiety, or sleep?18 Are you comfortable seeking professional help for struggles you might be facing? Resilience is also a significant part of wellness. How well do you bounce back from a tough case, a bad outcome, an error, a lawsuit, a stretch of shifts, an overnight shift, a personal or family problem, any conflict, or financial stress?19 Wellness is central to your resilience, and resilience is central to your wellness. Both are essential to your general health and for your overall performance. It’s wise to pay close attention to them at all times, not only when things become challenging. Consider developing a consistent mindfulness practice you can rely on during work and during personal time. Many studies by numerous authors have demonstrated the benefit of keeping a gratitude journal, although I urge you to avoid using social media as your “journal.” 5. Mentorship

Mentors and mentorship have proven to be critical to the development and advancement of professionals at all levels. Seek mentorship. It isn’t necessary to have mentors with similar backgrounds, or shared gender or ethnic characteristics. It is quite reasonable to have more than one mentor, even someone from outside of EM. However, it is best to find mentors who share similar values and desire to help you achieve your goals (not their own). Make and take time to reach out to mentors for advice, wisdom, and help supporting your growth. A mentoring relationship increases the likelihood of success and improves performance outcomes. Greater job satisfaction, faster promotions, higher salaries, and increased productivity are only a few outcomes of having (and working with) a strong mentor or mentors. Discuss with your mentor the best

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ways to maintain joy and meaning in your work. Gain their advice about work-life harmony (a term I prefer over the phrase “work-life balance”).20-22 I wish you the very best during the remainder of your training and throughout your career. It is always beneficial to develop new skills, to invest time learning more about topics you might not know as well as you could, to improve efficiency and communication, and to actively pursue mentorship. There is no weakness in focusing on your own health and wellness, seeking advice, understanding your limitations, and being dedicated to continuous learning and improvement. I have great respect for what you are doing and all that you’ve accomplished so far in your careers. I hope you are proud of your triumphs and achievements as well. Editor’s Note: This article originally appeared on emresident.org, an official publication of the Emergency Medicine Residents’ Association, and is reprinted with permission. References *emra.org/emresident/authors/gus-garmel 1. Gaddis G. Emergency Medicine Deserves to “Re-Brand” Itself as a Cost Saver. ACEP Now. July 6, 2023. Accessed 8/22/23. 2. Zink BJ. Anyone, Anything, Anytime: A History of Emergency Medicine, 2nd ed. ACEP Publ. Dallas, Tx. 2018. 3. Kilaru AS, et al. Boarding in US Academic Emergency Departments During the COVID-19 Pandemic. Ann Emerg Med 82(3):247-254. 4. Kanzaria HK, Cooper RJ. The Unspoken Inequities of Our Boarding Crisis. Ann Emerg Med 82(3):255-257. 5. Budd K. Rising Violence in the Emergency Department. AAMC.org. Feb 24, 2020. 6. ACEP Emergency Department Violence Poll Research Results. August 2022. Accessed 8/21/23. Countinued on page 29 >>

JUSTICE, EQUITY, DIVERSITY, AND INCLUSION SECTION

Adding Insult to Injury: Resident Mistreatment in Emergency Medicine Mel Ebeling, BS and Cortlyn Brown, MD

hen considering the state of resident mistreatment in emergency medicine (EM), the idiom “to add insult to injury” comes to mind. At this point in 2023, it is well-known by most in the field that interest in EM has significantly declined over the past couple of years, as seen through the Match. Yet, those medical students who have a passion for EM and have worked hard to obtain a spot in their dream program come to experience discrimination and abuse after entering residency.1 For residents who are underrepresented in medicine, Continued mistreatment of residents at a this issue is unfortunately exacerbated, and there are systemic level is not only unacceptable, but, chilling accounts of just how severe an impact disin the setting of already low interest, is just crimination can have on one’s residency experience.2,3 Continued mistreatment of residents at a systemic level not good business either. is not only unacceptable, but, in the setting of already low interest, is just not good business either. How deep is this problem, and what can be done to develop a diverse EM workforce increasing diversity in residency training programs.5 However, diversity may be increased further by focusing on holistic application review, allythat is free from mistreatment? ship training, and social media recruitment strategies.5 At the Highland Few studies have dared to explore mistreatment in EM residency proEM Residency Program, a two-fold increase in underrepresented minorigrams, but the ones that have have produced depressing results. A study ty residents was achieved through a more holistic application review prothat surveyed over 7,600 EM residents found that nearly half reported cess, robust diversity committee, and diversity applicant week.6 However, exposure workplace mistreatment (such as discrimination, abuse, or diversification of EM is only half the battle. As it pertains to mistreatment harassment) within the previous academic year.1 Types of mistreatment of residents (especially those underrepresented residents), several included discrimination based on gender, sexual orientation, pregmeasures have been identified. Education on responding to events of nancy/childcare status, and race/ethnicity, as well as verbal/emotional mistreatment, intentionality training, zero tolerance policies, and clear abuse, physical abuse, and sexual harassment. While in the majority reporting instructions are just a few ways that EM training programs of cases patients or the patients’ family members were the sources of progress.7 the mistreatment, the amount of mistreatment coming from attendings, AAEM prides itself as the champion of the emergency physician. This inresidents/fellows, and nurses or other staff is still alarming. This miscludes every emergency physician. The AAEM Justice, Equity, Diversity, treatment comes with serious consequences—both suicidal thoughts and Inclusion (JEDI-AAEM) Section has heard the concerns of the and burnout have been associated with the frequent mistreatment of 4 mistreated and is committed to ensuring that prejudice and discrimination residents. in residency programs are not tolerated. We encourage you to review It is simply necessary, then, that EM recruit more diverse physicians our publication, the “AAEM Position Statement on GME Response to who better represent the population our field serves, while also creating Resident Discrimination,” which outlines our recommendations for inan environment where trainees are treated fairly and discrimination creasing diversity and reducing mistreatment in the training environment. is truly minimized to the greatest extent possible. There has been We also encourage you to consider joining our Section as we work to considerable effort put into determining how these two goals can be advocate for diversity, equity, and inclusion on a large-scale. >> achieved. Focused recruiting on interview days, implicit bias training, and formal mentorship opportunities have all previously been successful in

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JUSTICE, EQUITY, DIVERSITY, AND INCLUSION SECTION

AAEM prides itself as the champion of the emergency physician. This includes every emergency physician.

Residents are not a means to an end, cogs in the healthcare machine. Rather, they are ends in themselves that deserve to be supported and looked after with intent and care. It is the responsibility of everyone in emergency medicine to rally behind our trainees who are the future of the specialty. This starts with creating programs and hospitals that prioritize and celebrate the individual resident and their wellbeing throughout their training.

References 1. Lall MD, Bilimoria KY, Lu DW, et al. Prevalence of Discrimination, Abuse, and Harassment in Emergency Medicine Residency Training in the US. JAMA Netw Open. 2021;4(8):e2121706. Published 2021 Aug 2. doi:10.1001/jamanetworkopen.2021.21706 2. Amaechi O, Rodríguez JE. Minority Physicians Are Not Protected by Their White Coats. Fam Med. 2020;52(8):603-603. https://doi.org/10.22454/ FamMed.2020.737963. 3. Ray R Jr. Racism in Medical Education: An Unfortunate Ending To My Time At Lehigh Valley Health Network. Published June 15, 2023. Accessed September 16, 2023. https://rrayjr.blog/2023/06/15/racism-inmedical-education-an-unfortunate-ending-to-my-time-at-lehigh-valleyhealth-network/ 4. Lu DW, Zhan T, Bilimoria KY, et al. Workplace Mistreatment, Career Choice Regret, and Burnout in Emergency Medicine Residency Training in the United States. Ann Emerg Med. 2023;81(6):706-714. doi:10.1016/j. annemergmed.2022.10.015

5. Crites K, Johnson J, Scott N, Shanks A. Increasing Diversity in Residency Training Programs. Cureus. 2022;14(6):e25962. Published 2022 Jun 15. doi:10.7759/cureus.25962 6. Garrick JF, Perez B, Anaebere TC, Craine P, Lyons C, Lee T. The Diversity Snowball Effect: The Quest to Increase Diversity in Emergency Medicine: A Case Study of Highland’s Emergency Medicine Residency Program. Ann Emerg Med. 2019;73(6):639-647. doi:10.1016/j. annemergmed.2019.01.039 7. Griffith M, Clery MJ, Humbert B, et al. Exploring Action Items to Address Resident Mistreatment through an Educational Workshop. West J Emerg Med. 2019;21(1):42-46. Published 2019 Dec 9. doi:10.5811/ westjem.2019.9.44253

AGING WELL IN EMERGENCY MEDICINE INTEREST GROUP

Countinued from page 19

Retirement planning is not only concerned with financial issues but also with the physician’s physical and emotional health. We generally identify strongly with our profession and retirement can lead to a loss of identity, purpose, goals, and self-worth as well as a loss of intellectual stimulation and social interactions.6,7 Daunting, to say the least. The benefits of mentorship into retirement can extend beyond receiving guidance, no matter how personalized, and into the realm of social-emotional health.

The same community that we build to support each other throughout our careers can help us navigate our lives post-career. This is something we can achieve. We know the colleagues who can help—maybe you are one. Mentorship is something we should do to support our colleague and peers for the whole span of their careers in emergency medicine.

References 1. Long B, Koyfman A. Mentoring and Emergency Medicine-Part 1 2017 March 23 2. Ng SM, Leng L, Wang Q. Active interest mentorship for soon-to-retire people: A self-sustaining retirement preparation program. Journal of Applied Gerontology 38 (2019): 344-364. 3. Silver MP, Hamilton AD, Biswas A, et al. Life after medicine: a systematic review of studies of physicians’ adjustment to retirement. Arch Community Med Public Health 1 (2016): 26-32. 4. Silver MP, Easty LK. Planning for retirement from medicine: a mixedmethods study. CMAJ open 5 (2017): 123 5. Bard, ML To Retire or Not: That is the Question. Ann Emerg Med 66(4) (2015) 428-9 6. Physician Specialty Data Report. AAMC. (n.d.). https://www.aamc.org/ data-reports/workforce/report/physician-specialty-data-report

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7. Aly, Allan Stolarski, Patrick O’Neal, Edward Whang, Gentian Kristo. The Current Status of Retirement Mentoring in Academic Surgery in the United States. Journal of Surgery and Research 2 (2019): 70-76. 8. Silver MP, Hamilton AD, Biswas A, et al. Life after medicine: a systematic review of studies of physicians’ adjustment to retirement. Arch Community Med Public Health 1 (2016): 26-32.Noone J, Stephens C, Alpass F. Preretirement planning and well-being in later life: A prospective study. Res Aging 31 (2009): 295-317. 9. Onyura B, Bohnen J, Silver I, et al. Reimagining the self at late-career transitions: How identity threat influences academic physicians’ retirement considerations. Academic Medicine 90 (2015): 794-801. 10. Cronan JJ Retirement: its not about the finances. J Am Coll Radio 2009 Apr 6 242-5 11. Noone J, Stephens C, Alpass F. Preretirement planning and well-being in later life: A prospective study. Res Aging 31 (2009): 295-317.

WELLNESS COMMITTEE

#StopTheStigmaEM Month: An Acknowledgment of the Hard Job We Have as Emergency Physicians Amanda J. Deutsch, MD* and Al’ai Alvarez, MD†

he second annual #StopTheStigmaEM Month campaign began with a panel discussion on October 4, focusing on normalizing mental health and mental healthcare for emergency medicine physicians. Panelists included leaders from the American Academy of Emergency Psychiatry and the Coalition of Psychiatric Emergencies: Drs. Junji Takeshita, Tony Thrasher, Leslie Zun, Karen Lommel, and Lisa Wolf. We delved into recognizing the inherent occupational hazards in emergency medicine that jeopardize mental health. These hazards, such as daily encounters with vicarious trauma, moral injury, mistreatment, and burnout, can lead to increased risks of depression, anxiety, and suicide. It’s crucial to note that poor mental health doesn’t equate to mental illness, and having a mental illness diagnosis doesn’t necessarily imply poor mental health. Proactively addressing mental health, akin to physical health, doesn’t denote impairment at work or having a diagnosed illness while working on mental health. As one physician noted, “Being an EM physician is tough, and the responsibility is heavy. We do this work with pride. This can all add up over time. This does not have to be a DSM diagnosis. This can be looked at as an occupational hazard.” When it comes to on-shift mental health and awareness, a straightforward strategy involves fostering an environment of mutual encouragement. If you haven’t been doing this, it’s relatively easy to accomplish. Encouraging each other’s experiences at work can include checking in on one another. Importantly, this doesn’t have to happen in the moment, and the ability to persevere despite a tough shift doesn’t have to be interrupted. Recognizing that some of us may not be ready for an immediate check-in is crucial. Many of us compartmentalize as a coping mechanism and may not be prepared to discuss things right away.

Utilizing our friends and family outside of work can also be tricky as they may not understand what we experience as emergency physicians. “The only people who really understand what it’s like are people who are doing it,” and describing our experience to those who may not understand what we do may be traumatizing for them. “We can only do this for so long.” Instead, the panel suggested that we find other ways of connecting with our friends and family. Isolating ourselves can be dangerous. We may not want to tell our families of components of our work that we have difficulties grappling with, and so we must find ways to stay involved with our friends and family because we will be thinking about this no matter how hard we try.

It’s crucial to note that poor mental health doesn’t equate to mental illness, and having a mental illness diagnosis doesn’t necessarily imply poor mental health.

We can be transparent with our friends and family that “What’s bothering us is not always going to be of the most assistance. But spending time with them, and being there for them, and still living that parts of our lives not attached to our work life is very important.” This means we can choose to be just the partner or the parent or friend.

The panelists suggested supporting a colleague who might be “in the weeds” by handling calls and messages immediately after a critical event. If someone is unable to handle a check-in immediately or “in the moment,” that’s okay. We must normalize having “downtime.” This could mean being able to take a walk or grab food. Another opportunity is making a note of the incident you observed, then checking in on your colleague a few days later with a simple, “That shift the other night looked really hard, how are you?” These moments allow us to feel seen and be reminded that we are not alone.

For some, this means hugging our loved ones extra tightly after a rough shift.

Taking pride in the hard work we do is essential, and it’s equally okay to take care of ourselves. Modeling these self-care behaviors for our colleagues is equally important. We can acknowledge challenging experiences by discussing our struggles and celebrations with peers. We can also take pride in working with our struggles and celebrations with a therapist. Normalizing mental health should be a collective effort.

References

We must create a culture of wellness where we normalize getting support while continuing to address systemic causes of burnout. We need both. Editor’s note: If you are in need of support, the Physician Support Line is here to help online at physiciansupportline.com or by phone at 1-888-409-0141 *SAEM Wellness Committee #StopTheStigmaEM Subcommittee Chair; Director of Well-Being; Thomas Jefferson Emergency Medicine; @ amandajdeutsch SAEM Wellness Committee Chair; Director of Well-Being; Stanford Emergency Medicine; @alvarezzzy

†

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WOMEN IN EMERGENCY MEDICINE SECTION

International Medical Students: Equally Prepared for the Field of Emergency Medicine Kadie Stephens, MS3 and Zoe Cole, MS4

he field of emergency medicine demands competent and skilled physicians who can navigate critical situations with unflappable confidence and expertise. During the 2023 match cycle, there were 554 unmatched emergency medicine residency spots. Historically, emergency medicine residency programs have not had to participate in the SOAP due to it being a competitive specialty. There are many reasons why this may have happened, but one reason for this surplus in open positions may unfortunately be due to bias. Almost every physician in academia is aware of the bias against international medical graduates (IMGs), particularly non-U.S. IMGs and Caribbean IMGs. As medical trainees, we have heard more than our fair share of negative comments about being IMGs. “You would be better off marrying rich than trying to be successful coming from a Caribbean school,” or “You’re not going to make it as a doctor and will end up without a job if you go to a Caribbean medical school,” and there’s always the seemingly favorite comment that “You won’t get into a competitive specialty as an IMG.” There are endless misconceptions about IMG students. As U.S.-IMG students, both from the Midwest, we believe that these are not the thoughts that should be at the forefront of a person’s mind when they think of IMG physicians and trainees. We believe that international medical students are just as prepared to enter the field of emergency medicine as their U.S. medical school colleagues, highlighting the diversity and inclusivity they bring to healthcare settings.

It is crucial to acknowledge and appreciate the contributions [international medical graduates] make to the U.S. healthcare system, fostering inclusivity and positively impacting patient care. One of the key advantages of international medical students is the diversity they bring to the field of emergency medicine. Though many of the students may have been born and raised in the U.S., they come from various cultural backgrounds, exposing them to different healthcare systems and perspectives. Many of these students are also “non-traditional,” meaning that they have had other careers prior to medical school, such as nurses, physical therapists, or even investment bankers, before attending medical school. Their diverse experiences and understanding of healthcare challenges make them well-equipped to tackle the culturally diverse patient populations frequently encountered in emergency medicine. 26

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A common, and unfortunately prominent, misconception is that international medical schools are less rigorous than U.S. medical schools. While the average MCAT score of international medical students attending Caribbean medical schools may be lower compared to U.S. medical school students for the sake of higher matriculation, it does not imply inferior knowledge or clinical skills. International medical schools often provide rigorous training programs, focusing on practical skills development and clinical exposure. These programs also have shown high first-time pass rates on the USMLE STEP 1, STEP 2, and STEP 3, with scores that coincide with the U.S. national averages. Also, many Caribbean medical students have their clinical science years at top-tier American medical institutions such as Cleveland Clinic, Mt. Sinai Medical Center, Jackson Memorial Hospital, University of California-Kern Medical Center, and many more. Moreover, these schools understand the unique challenges faced by minority students who were pushed out of the highly competitive U.S. medical school system. An attribute that most people might not think about is the adaptability and resilience of international medical students. We spend days, if not weeks, without power or water during hurricane season, studying with our flashlights and using bottled water to brush our teeth, the unfortunate aftermath of weather wreaking havoc on a small island. Basic necessities were even sometimes hard to come by, as the grocery stores only carried so many items. When they did have the items, they were at ridiculous prices. For example, after weeks of the grocery store not getting a grocery barge, we saw milk for $10 USD a liter! The experience only makes us stronger. IMG students, by virtue of studying abroad, demonstrate resilience, adaptability, and the ability to navigate new environments effectively. These qualities are essential in emergency medicine, where quick decision-making and effective problem-solving are vital. Additionally, their exposure to diverse healthcare systems, both in the U.S. and abroad, during their training allows them to bring fresh perspectives and alternative approaches to patient care, contributing to a more comprehensive and globally informed practice. International medical students, including those attending Caribbean medical schools, are equally prepared to enter the field of emergency medicine as students who train in the United States. Their diverse backgrounds, rigorous training programs, adaptability, and global perspectives equip them with the necessary skills to handle emergencies effectively. These are the stereotypes we wish to instill in people when they think of IMG students instead of thinking we “took the easy way out by going to a Caribbean school,” or wondering if we trained in U.S. clinical sites and can speak English. It is crucial to acknowledge and appreciate the contributions these students make to the U.S. healthcare system, fostering inclusivity and positively impacting patient care. In this day and age where there is a huge focus on diversity and inclusion why aren’t IMGs in the picture?

JUSTICE, EQUITY, DIVERSITY, AND INCLUSION SECTION

Why Residency Programs Should Expand Their Definition of Underrepresented in Medicine to Include LGBTQ+ Applicants Madi McDole, MS4, Kristin Fontes, MD FAAEM FACEP, Mel Ebeling, MS3, and Kelsey Newbold, MS4

hether it was intentional or not, many of us chose to enter Emergency Medicine (EM) for reasons of diversity. There is the “jack of all trades” diversity in chief complaints from chest pain to vaginal bleeding that enthralls and excites us (until an eye complaint comes in). There is diversity in disease pathology that always keeps us on our toes and wracking our brain for those possible “atypical” presentations. For many, it was the diversity of our patients and the ability to influence the social determinants of health that solidified our desires to enter EM. As a gateway to care, we see how factors such as insurance coverage, language barriers, race, zip codes, and SES impact the health of our patients. While we practice in a field built on the core of diversity, do we as physicians emanate the same diversity in our workforce? Does the medical field look as diverse as the populations we serve? A recent survey by Gallup reported that 7.1% of the US population identifies as LGBTQ+, nearly doubling from 3.5% in 2012.1 Importantly, one in five Gen Z youth identify as queer. With this rapidly growing population with specific healthcare needs, is our physician workforce similarly expanding to include LGBTQ+ physicians? According to the AMA, only 3.4% of physicians identified as LGBTQ+, suggesting that there is underrepresentation of this population in medicine. Why is queer representation in medicine so important? There is stigma and active discrimination of LGBTQ+ patients that influences their care. Multiple studies have evaluated physician and resident perceived need of inclusive healthcare for queer patients with the vast majority agreeing that LGBTQ patients deserve equitable healthcare.2 Yet, these same physicians report feeling uncomfortable caring for this population due to a lack of training. This discomfort has tangible consequences for patients with 21% of physicians maintaining poor eye contact, 45% avoiding conversations about sexual behaviors, and being less likely to perform procedures on LGBTQ patients.3 Transgender patients are more likely to postpone healthcare utilization due to fear of discrimination.4 While part of the solution is increasing queer health education, this problem desperately requires systemic change.

As emergency medicine physicians, we encounter and celebrate diversity on a daily basis. All we need to do now is expand the definition of it.

To help combat this inequity, we must enlist more LGBTQ+ physicians into the medical field. Medicine has historically been a cisgender white man’s game. For decades, the U.S. has grappled to overcome systemic racism and sexism that has driven admission into higher education. Following the desegregation movement in the 1960s, the Association of American Medical Colleges (AAMC) created the definition of Underrepresented in Medicine (URM) to improve medical school recruitment of “Blacks, Mexican- Americans, Native Americans, and…Mainland Puerto Ricans.” Following the 2003 Supreme Court case of Grutter v. Bollinger that ruled in favor of racial/ ethnic diversity in higher education admissions, the definition was expanded to include “racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.”5 While this wording alone suggests a broadened view of diversity, the AAMC further specifies this to only include students that identify as “American Indian or Alaska Native; Black or African American; Hispanic, Latino, or of Spanish Origin; or Native Hawaiian or Other Pacific Islander.” If the intention of the AAMC’s URiM statement is to advocate for a diverse medical profession that resembles the general population, we must ask ourselves if racial and ethnic diversity is the only facet to consider. With the AAMC’s limited definition of URiM, there is no clear way for students to self-identify or for residency programs to actively increase their recruitment of openly queer physicians. That is why we are encouraging emergency medicine residency programs to expand their definition of URiM to include LGBTQ+ students. This would allow for increased diversity in our specialty, more opportunities for mentoring, and scholarships for those passionate about LGBTQ health. Countinued on page 35 >> COMMON SENSE NOVEMBER/DECEMBER 2023

Corporate Medicine is Not Compatible with Residency

AAEM/RSA PRESIDENT’S MESSAGE

Leah Colucci, MD MS

or profit hospitals are an ethical concern in residency training. I have said numerous times, the only thing cheaper than a midlevel is a resident. Furthermore, residents are more productive and make fewer medical errors. Additionally, government funding is provided per resident to the hospital, subsidizing the cost. If I were a money-hungry CEO at a for profit system, the first thing I would do is staff my ED with as many midlevels and residents as I could. Next, I’d find a tired, burnt-out physician to borrow their medical license while they staff the patients of all my PAs and residents. This model is what too many of our departments are doing and should show why any time a CMG and/or for-profit hospital system opens a residency—you should raise your eyebrows. That said, I am not condemning all CMG programs. I am condemning the ones that do not prioritize their resident’s education. We need to ensure that we are training the highest quality EM physician. RSA over the years has received numerous reports from residents that their programs are not doing what they promised the ACGME they would. Some tell us that they are having difficulty obtaining procedures—whether it be a PA taking their procedures or an attending that is RVU based

Residents, don’t be afraid to speak up about problems in your institution, you could be saving a generation of residents to come!

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and will see more patients on their own than if they took the time to supervise a procedure. Other residents report that due to the staffing model of their department their attendings are so swamped they do not have time for on shift teaching or adequate supervision. This data was seen by a recent study conducted by AAEM that showed residents were concerned by midlevels taking learning opportunities on shift and they did not trust that the ACGME would support them. When residents have come to me with complaints, I always ask if their program is reporting this on their resident survey. Nine times out of ten, residents tell me that they are not reporting issues directly to the ACGME or on the survey. They are more afraid of their residency being shut down than they are of not getting an appropriate education. What residents need to know is being honest on the ACGME survey will not shut down the program. Instead, it will initiate an evaluation, maybe a warning and at the very most a probation. None of this means immediate program closure. Triggering a site visit could even help alert leadership that changes are needed and this may not only provide more support to residents, but attendings. It likely would only result in a positive change for future residents. Regardless, medical students are not dumb applicants. They are approaching the match looking for programs that are supporting wellness and education. In a recent study by Preiksaitis, six program characteristics were associated with unfilled PGY1 positions in the 2023 match. A corporate ownership structure was one of those six characteristics and further amplifies that applicants are in tune with the growing concerns for the future of EM. While the 2024 Match has now had an increase in overall application numbers to EM—the number of U.S. MD applicants has continued to decline. Applicants, the ball is in your court, if you continue to avoid for profit groups willing to exploit you, maybe the leadership will pay attention. Residents, don’t be afraid to speak up about problems in your institution, you could be saving a generation of residents to come! Resources: 1. aliem.com/mismatch-unfilled-emergency-medicine-residencypositions2023/

A Glow-Worm’s Reflection on COVID-19

AAEM/RSA EDITOR’S MESSAGE

Mel Ebeling, BS

f there was anyone more prepared to battle the pandemic face-to-face, I thought it would be me. Over the past several years, I had spent hundreds of hours training to respond and mitigate hazardous materials incidents of all breeds, including chemicals, biologicals, radiologicals, and even explosives. This training took me across the country: in the deserts of New Mexico, I observed a dozen or more IED explosions; at a security site just southwest of Area 51, I learned to monitor the radiation left over from the hundreds of nuclear test explosions conducted during the Cold War; and at a former military base in Alabama, I trained in a live toxic agent environment with chemical warfare agents, VX and GB, and biological warfare agents, anthrax and ricin. Not once, but four times, all thanks to the Department of Homeland Security. I cannot count the number of times I have donned PPE, ranging from wearing a simple powered air-purifying respirator (PAPR) over Tyvek coveralls on one end of the spectrum to buckling myself into a self-contained breathing apparatus and encapsulating myself in a neon green “moon suit” on the other end. (These Level A suits are why hazardous materials specialists are often called “glow-worms.”) Truly, I felt confident in my ability to navigate dangerous situations. And yet, when COVID-19 first made its way into the United States, no amount of personal protective equipment (PPE) could protect me from my own cockiness and feelings of invincibility. As the masses flooded to the stores in a frenzy to buy toilet paper and hand sanitizer, I was calm and collected. And why wouldn’t I be? I had been around far more

lethal substances, ones that, with as little as 1/50th of a drop, could land me convulsing on the floor and dead in minutes. How bad could “the sniffles” be?

If there was anyone more prepared to battle the pandemic face-to-face, I thought it would be me...If there is anything I have learned in all my training, it is to respect the hazard.

An EMT at the time, it was not long after the announcement was made that COVID had spread to Alabama that I began to treat those plagued with the disease. Instead of a lavish PAPR and full-body coveralls, I trod through patients’ homes in a flimsy N95, gloves, and, when available, a paper-thin gown. When I saw the panic-stricken eyes of my first patient, a young man close in age to myself, struggling with each breath, I realized the severity of the epidemic. In this moment, I saw the faces of my parents, grandparents, friends, even myself transposed on his, now understanding the tragedy that could befall any one of us.

I felt naked, as if I was wearing no PPE at all, and these feelings of vulnerability have remained. If there is anything I have learned in all my training, it is to respect the hazard. As new COVID vaccine boosters roll out, I encourage everyone to consider the risks and benefits of updated immunization. As we all fully appreciate now, “the sniffles” really can be that bad, and the need for continued vigilance against infection is crucial.

ADVICE TO SENIOR EM RESIDENTS (ACTUALLY, ALL RESIDENTS AND FELLOWS)

Countinued from page 22 7. Rizvi S. Exorcising the CMG Demons of Emergency Medicine. Emerg Med News Oct 20, 2020. DOI: 10.1097/01.EEM.0000721172.11584.6f 8. Pines JM, Aldeen A. Questions You Should be Asking About How Your Physician Group Works. August 19, 2023. Accessed 8/21/23. 9. Garmel GM. Career Planning Guide for Emergency Medicine (2nd ed). Emergency Medicine Residents’ Association. EMRA Publication. Irving, TX 2007. 10. Garmel GM. Mentoring in Emergency Medicine. In Practical Teaching in Emergency Medicine, 2nd ed, Rogers RL (ed), Wiley-Blackwell, UK 2013. 11. Garmel GM. Mentoring Medical Students in Academic Emergency Medicine. Acad Emerg Med 2004;11:1351-7. 12. Strauss RW, Garmel GM. Conflict Management. In Strauss & Mayer’s Emergency Department Management. ACEP Publication, Dallas, TX. October 2021, pp 113-132. 13. Garmel GM. Conflict Resolution in Emergency Medicine. In Emergency Medicine: Clinical Essentials, 2nd ed. Adams JG, et al (eds). Elsevier/ Saunders, Philadelphia, PA 2013, pp 1743-1748 (an extended version of this chapter is published on-line at ExpertConsult.com). 14. Doerr J. Measure What Matters: How Google, Bono, and the Gates Foundation Rock the World with OKRs. Portfolio/Penguin, New York, NY, 2018. 15. Weizberg M, et al. Pilot Study on Documentation Skills: Is there Adequate

Training in Emergency Medicine Residency? J Emerg Med 2011; 40(6):682-6. DOI: 10.1016/j.jemermed.2009.08.066 (accessed 8/21/23). 16. ACEP 2023 Emergency Department Evaluation and Management Guidelines. Accessed 8/21/23. 17. Murthy VH. Together: The Healing Power of Human Connection in a Sometimes Lonely World. Harper Wave (Harper Collins), New York, NY 2020. 18. Votey SR. It’s Time to Wake Up to the Use of Pharmacologic Sleep Aids by Emergency Physicians. Ann Emerg Med 2019;73(4):3302. DOI: 10.1016/j.annemergmed.2018.09.035 (accessed 8/21/23). 19. Cross R, Dillon K, Greenberg D. The Secret to Building Resilience. Harv Bus Rev Jan 29, 2021. Accessed 8/21/23. 20. Coates WC. Being a Mentor: What’s in it for Me? Acad Emerg Med 2012;19:92-7. 21. Yeung M, Nuth J, Stiell IG. Mentoring in Emergency Medicine: The Art and the Evidence. CJEM 2010;12(2):143-149. 22. Giesler J. Let’s Replace the Term ‘Work-life Balance.’ Journalism Institute National Press Club. Oct 18, 2021. Accessed 8/21/23.

COMMON SENSE NOVEMBER/DECEMBER 2023

LEADERSHIP ACADEMY

SWOT… or TOWS: The First Leadership Academy Touchback Christopher Doty, MD MAAEM FAAEM and Loice A. Swisher, MD MAAEM FAAEM

t the Scientific Assembly in New Orleans, Dr. Robert Lam, our AAEM at-large board member, unveiled a redesigned, reimagined Leadership Academy. This new Leadership Academy brought mentor/mentee dyads together for an afternoon as an introduction to a year-long, mentee-chosen project with intermittent “touchback sessions.” The first touchback session featured a conversation with two Masters of AAEM, Drs. Christopher Doty and Loice Swisher, reflecting on the development of National Physician Suicide Awareness Day (NPSA Day) as an example of dyads working together to bring a project to successful completion. The idea of NPSA Day began with a crisis. A second year resident killed himself in 2016 at Dr. Doty’s residency. Three days after the resident’s death, Dr. Doty wrote an open letter to the CORD listserv asking members to shine light on physician suicide as a legacy to this young resident. Drs. Doty and Swisher used a SWOT analysis to discuss the journey from that beginning to first NPSA Day on September 17, 2018.

Threat — “Argue for your limitations and sure enough, they are yours”- Richard Bach

This quote is a favorite of Dr. Doty. In fact, he recommended the book from which it comes, “Illusions of a Reluctant Messiah,” to Dr. Swisher who struggled with her worth having been absent from academic medicine and the national stage for more than a decade and half. This hiatus was due to her daughter’s brain cancer treatment and resultant disabilities during which she considered suicide. In early 2016, she didn’t seek position, professional relationship, or content knowledge.Dr. Doty’s letter coming close after Christmas, she would often say that she was like the little drummer boy only bringing a song. She didn’t see the power of personal story—especially regarding physician suicide.

Apportunities — “Never waste the opportunities of a good crisis.”

Dr. Doty shared this quote from one of his mentors. As an experienced program director, he was devastated by being blindsided by his resident’s death. It was never something that he considered. It wasn’t something that he was prepared for—and he knew if it could happen to him, it could happen to anyone. By exposing his personal turmoil, not only would other educators want to support him, but also they would might uncover some anxiety about the potential that it could happen to one of their residents. This created a desire to “do something” within CORD. On a personal level, Dr. Doty had a mantra that he was going to “leverage what he had” to bring light to physician suicide. He had national positions in AAEM and

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CORD along with professional relationships across the country which he would use to focus attention on this topic.

Weaknesses — “Synergy: The combined effect of

individuals in collaboration that exceeds the sum of individual effects.” - Stephen Covey

In February 2018, a group of five CORD members met for a Mental Health Task Force phone conference. One member, Dan Lakoff, suggested that we should do something for National Physician Suicide Awareness Day. To which Dr. Swisher, now a member of the American Association of Suicidology, an organization older than emergency medicine, answered “I don’t think there is one of those but we could make one.” The decision of date was relatively easy as September was already designated Suicide Awareness month but we didn’t want to interfere with Labor Day or 9/11. A week after World Suicide Awareness Day, September 10, would have our day fall right in the middle of the month which could work well to arrange resident activities. Then the business-minded Dr. Dan Lakoff, said “We should have a logo.” Dr. Swisher responded the colors should be teal and purple but I have no idea how to make a logo. Another member had a family member who was a graphic designer who made the logo. Dr. Doty, as CORD President-elect and resilience committee board liaison, navigated the process for budgetary approval for CORD. Ultimately, that logo made all the difference in spreading the word of NPSA day on social media. The AMA, ACGME, multiple county medical societies, the Surgeon General, and even the UK’s National Health System tweeted out the logo on September 17, 2018. No one on that call had the ability to make a logo but the sharing of what we didn’t know had others fill in the gaps.

Strengths — Know Your Why AAEM Board member, Dr. Kimberly Brown, noted that knowing one’s why can be one of the greatest strengths. Knowing one’s why gives purpose, direction, and determination. A stunning example of this is from comedian Michael Jr Breaktime. He asks a musical director audience member to sing Amazing Grace. He then asked him to sing again with giving him the why he was singing. Knowing one’s why can make what you do more impactful. You are walking in or towards your purpose. SWOT is a tool one can use to clarify issues in your project and deliverables. Proper use of this often requires a broad look at one’s abilities and strengths. You must be honest with yourself about what the group has. Editor’s Note: If you are interested in learning more about the Leadership Academy or being involved in the next cycle, please contact Dr. Robert Lam or Dr. Kimberly Brown at info@aaem.org.

LEADERSHIP SPOTLIGHT:

Run for a Section Council in 2024! Cara Kanter, MD FAAEM

024 is fast approaching. What are your professional goals for this year? Consider how getting more involved in AAEM can help advance them! With the ever-growing committees, interest groups, and sections, there are more AAEM leadership opportunities than ever. Section Council election season is just around the corner, and I can bet there is at least one AAEM Section that aligns with your unique interests. You may already be a member of one or more sections. This year, I challenge you to take the next step and run four a council position. Many past and present AAEM leaders have gotten their start through Section leadership. It provides an introduction to the overall organization, allows for relevant skill development, and offers a natural progression to other leadership opportunities. Section councils take on everything from writing key position statements, event planning, education and advocacy work, and countless public speaking opportunities. This year, we welcome the Operations Management (OMS) and Locum Tenens (LTS) Sections to a robust family that also includes Critical Care Medicine (CCMS), Emergency Medical Services (EMS), Emergency Ultrasound (EUS), Justice, Equity, Diversity and Inclusion (JEDI), Women in Emergency Medicine (WiEM), and Young Physicians (YPS). Councilor, Secretary/Finance Chair, Chair-Elect, and RSA Representative positions will be available for each section— plenty of leadership opportunities for students, residents, fellows, and full voting members. Each section council meets regularly throughout the year by zoom. Join a section today. Already a member? Join a work group. Log in to an upcoming council meeting and see for yourself what your section is up to—all meetings are open to all section members. Join me and representatives from all eight sections on January 16, 2024, for a special virtual Q&A panel where you can meet the current section leaders and have any lingering questions answered in real time. Nominations open on January 29, 2024, and close on February 27, 2024, and elections run from March 27 to April 14, 2024. Section Council leadership will be announced on April 15, 2024, and will take effect on April 30, 2024 during AAEM 24 in Austin. Self-nominations are strongly encouraged and prior section experience is not required to run for a position!

With the ever-growing committees, interest groups, and sections, there are more AAEM leadership opportunities than ever.

Visit the AAEM Section webpage at aaem.org/get-involved/sections (or scan the QR code) to learn more and start getting involved today!

COMMON SENSE NOVEMBER/DECEMBER 2023

OPINION

An Emergency Medicine Physician’s Perspective on Gun Violence and Gun Control Preston A. Ball, MD

s an emergency medicine physician practicing in a level one trauma center, you might think that I am tired of gun violence and wished that it would stop, that measures that would actually curb the incidence of people shooting each other should be implemented. And you would be right.

As a healthcare professional, my inner compass points towards preservation of life and alleviation of pain and suffering. The overall medical community shares these goals, and to a large part embraces laws that restrict access to firearms, certain types of firearms, lawful transfer of firearms, magazine capacities, and limitations on where firearms may be legally carried. To the naïve and uninitiated, these may seem like noble and effective endeavors. However, as it always does, reality eventually rears its ugly head. As an emergency medicine physician and public safety veteran with 35 years of field experience in fire, EMS, and tactical law enforcement, my work arena is far from the protected ivory tower of the elites, guarded by gated communities and armed security, who often espouse the proposed societal benefits of strict gun control laws. My experience, however, as well as following social and societal trends, has made some observations clear.

Violence is prevalent in society and seems to be increasing. Despite misguided utopian claims to the contrary, violence is deeply embedded in human nature, has been a feature of the human condition since the beginning of time, and always will. To deny this irrefutable fact is to deny reality. And as individual citizens, we cannot rely on others to protect us. I am a strong proponent and advocate of law enforcement, but the reality is that they are predominantly a reactionary force, leaving the individual citizen on their own during the crucial first moments of a violent encounter. The limitations of law enforcement to safeguard the citizenry has been blatantly demonstrated during the past few years, with Covid lockdowns and restrictions on police response, as well as efforts to defund and further limit the ability of officers to engage in effective policing. The unfortunate victim of these measures has been the private citizen, who finds himself more and more alone and at the mercy of the violent criminal element. Criminals are using highly sophisticated and lethal weaponry more and more. Once limited to law enforcement and military arenas, rifles and effective hollow point pistol rounds are being increasingly utilized by criminals. The North Hollywood Bank of America shootout demonstrated

Criminals, by definition, do not obey these laws. To a large part they gain access to their weapons by illegal purchases and theft.

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AN EMERGENCY MEDICINE PHYSICIAN’S PERSPECTIVE ON GUN VIOLENCE AND GUN CONTROL

this to the world, where responding officers were so outgunned that they resorted to raiding local gun stores to procure rifles with equivalent firepower to effectively engage the robbers. Although they represent a tiny minority of firearm casualty victims, active shooters engaged in school, church, and public gathering incidents often use these weapons. Many are also receiving training through commercial firearms schools and underground training camps. When challenged with the current sophisticated and well-armed criminal element, the responsible individual citizen should have access to weapons of at least equal lethality to reliably employ in their own defense. A favorite talking point among proponents of stricter gun control measures involves the passage of more stringent gun laws that limit certain types of firearms, magazine capacities, transfer of firearms between individuals, and establishing “gun free zones” where the occupants and society in general would be safe. However, this viewpoint ignores an important fact: criminals, by definition, do not obey these laws. To a large part they gain access to their weapons by illegal purchases and theft. Restrictive gun laws only serve to disarm law-abiding citizens and substantially limit their ability to defend themselves against violent perpetrators who employ highly lethal implements of violence in blatant disregard to laws. While societal, judicial, and cultural factors contribute, this explains why areas with the most restrictive gun laws are among the highest in the nation with respect to gun violence, as criminals do not abide by laws and are emboldened by an unarmed populace that cannot defend themselves. Similarly, so-called “gun free zones” render their law-abiding occupants defenseless against criminals with nefarious intent, because, again, criminals do not follow the law. To a large degree, public perception of guns and gun violence is heavily slanted by the mainstream media, egregiously misleading, misrepresenting, and sometimes deliberately obfuscating data. A significant number of “gun violence deaths” are actually suicides, which is tragic and sad in its own right, but wholly unrelated to firearm incidents between individuals. Yet these suicides are added into the mix of interpersonal firearm deaths to inflate the numbers to generate fear, panic, and outrage. Similarly, “mass shooting” incidents are reported by the media in seemingly staggering numbers, but a large percentage of these events (where three or more persons are shot) involve urban gang shootings. This is, again, a tragedy in its own right, but the societal, cultural, political, and economic factors that contribute to these events will in no way be affected by restrictive gun laws that only serve to restrict the arming of the law-abiding citizenry, and will further erode their capacity to defend themselves against violent criminals. A recent and more preposterous example of data manipulation and suppression occurred last year with the CDC itself purposefully omitting data related to defensive firearm use that either prevented or terminated a violent encounter. As physicians, we have all learned to critically appraise medical data and trials to detect and interpret researchers’ results for accuracy, applicability, bias, and validity; so too should we interpret information presented by sources with an agenda with a healthy degree of skepticism.

The gun itself is neither virtuous nor evil; it is simply an inanimate tool, like a hammer, a knife, or a shovel, its benevolent or harmful use controlled solely by its user. The gun control lobby also uses tragedy and highly visible events such as school shootings to emotionally assault the public into “doing something.” These events, while horrific, are quite rare when filtered from the gang shootings referenced above, and essentially none would have been prevented by the proposed knee-jerk, feel-good, virtue signaling measures that have been proposed. Armed and vigilant security at these locations, however, would do wonders to limit and deter these incidents, converting a “gun-free zone,” or “free fire target rich environment,” into a “gun-patrolled zone” dedicated to protecting society’s most innocent and helpless members. In fact, data recovered from the recent Nashville Covenant school shooting revealed that the shooter had scouted several locations, but dismissed others due to a strong security presence, and instead chose the softer target of the Covenant school. It is a cliche, but the mantra that “the only thing that can stop a bad guy with a gun is a good guy with a gun” is true. Who does society send to defend us against armed entities that are determined to do us harm? The police and military, organizations of “good guys” with guns. Private citizens should likewise be equipped and empowered to defend themselves. Gun control does not resolve human violence, it only changes its tools of implementation. Areas where firearms are not present are not spared the ravages of interpersonal violence and aggression. Their incidence of gun violence is low, but made up for in stabbings, hackings, homicidal use of automobiles, and explosives. So the problem is not the gun. The problem is the people. Until humans can get along peacefully with each other, which has never happened in the history of human existence, virtuous people will need the ability to defend themselves, their families, their communities, and their countries against violent predators that seek to do them harm. The gun itself is neither virtuous nor evil; it is simply an inanimate tool, like a hammer, a knife, or a shovel, its benevolent or harmful use controlled solely by its user. Gun control is a naïve and misguided mindset. Granted, not everyone has the determination and fortitude to stand up to violent criminals and refuse to be a victim; that is fine, and I wish them well. Guns aren’t for everybody. However, to deny the endless cycle of violence that pervades our society and the necessity of armed self-defense is to deny reality, and that fictional utopia is nowhere I would tread unarmed..

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CRITICAL CARE MEDICINE SECTION

The Disutility of Sodium Bicarbonate in Metabolic Acidosis Emmie Potter, MD, Cara Gardener, MS, and David Gordon, MD

hile sodium bicarbonate (SB) is used in specific toxidromes, such as tricyclic antidepressant (TCA) or Aspirin (ASA) toxicity, its utilization to correct nonspecific metabolic acidosis remains controversial. In-vitro, animal and human studies have not demonstrated a consistent benefit of bicarbonate therapy and may suggest a signal for harm. While often given with the best of intentions, even the secondary outcomes of NaHCO3 have not been consistently shown in these studies.1 Data from retrospective human studies are mixed at best. Retrospective studies have been inconsistent in their outcomes. A propensity matched study of 348 ICU patients, with an isolated metabolic acidosis did not show any impact of 8.4% Bicarb on 20 day mortality.2 However, in the matched comparison there were some differences in baseline creatinine, norepinephrine, and blood product administration. In a separate analysis of the Medical Information Cart for Intensive Care (MIMC-III) database evaluating patients with septic shock and again purely metabolic acidosis, there was no difference in mortality.3 However, among those with a pH of <7.2 etiology matters, while SB improved mortality in those with AKI of stage two or greater, versus no improvement in those with a lactate of >2.2 or in those with GI losses of bicarb.3 This is counter to an analysis of the MIMC 320 propensity matched patients, found SB administration was associated with decreased mortality in those with sepsis and septic shock with moderate lactic acidosis.4 Lastly a 2021 multicenter retrospective study did show improvements in MAP at six hours in the bicarbonate group and trend towards ICU mortality, as well as the expected corrections in physiological derangements.5 Importantly this study did not have a matched cohort analysis.5 Taken together these studies imply that SB may be helpful for correcting underlying global metabolic acidosis, but don’t clearly or consistently show that SB impacts hemodynamics or mortality. There is of course large variability in these studies as far as patients, volume and type of bicarb administration, and geographical variability. There are three prospective trials that clearly demonstrate the futility of SB. One of the most interesting is in 14 mechanically ventilated patients receiving vasopressors with an average lactate of 7.8.6 Over a two hour period they were sequentially given 2mmol/kg of SB over 15 minutes and NaCl. The SB had the intended effect on pH and HCO3, and unsurprisingly PCO2 increased, but there was no difference on Wedge pressure, MAP, or cardiac output.6 A similar study on 10 critically ill patients with

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lactic acidosis all on dopamine and/ or dobutamine, had similar findings.7 They only used 1mmol/kg of SB as opposed to 2mmol/kg as in the previous study. One concern that is addressed is that improvement in pH may drive a change in 2,3 DPG and therefore decrease much needed oxygen delivery in the setting of acidemia, however this study did not find any change in 2,3 DPG concentrations.7 Conclusions from the above studies are mixed but it is safe to draw two conclusions: 1) simple correction of a pH is insufficient to improve hemodynamics and 2) if Bicarb does anything it is not an effect of correcting the plasma pH. Of course neither of these are clinical outcomes. There is only one large RCT of SB administration in critically ill patients; BiCAR ICU.8 This was a multicenter, randomized control trial at 26 French ICUs of adults with severe metabolic acidosis (pH <7.20, Bicarb <20, and CO2 <45). It included 389 patients, with a primary outcome of 28 day mortality plus one system of organ failure. There was no difference in the composite primary outcome or either of the components, though they all favored the bicarb group. However, in patients with AKI stage II and III (a prespecified subgroup) all three (death plus organ failure, death, organ failure) favored the bicarb group. While there were several secondary outcomes that favored the bicarb, patient oriented outcomes did not. Expected complications were more common in the bicarb group (metabolic alkalosis, hypokalemia, and hypoionized calcemia). This is most supportive of the retrospective data from the MIMC- III which also found a benefit in those with hypocalcemia.3 Overall, bicarb may alter the pH, but hasn’t been proven to change the hemodynamics beyond the same volume of another fluid. This may be because fixing plasma pH doesn’t change intracellular pH, and of course it doesn’t help obtain source control. Outside of a few prespecified scenarios there currently isn’t sufficient evidence to prove that bicarb changes any significant patient oriented outcomes. References 1. Forsythe SM, Schmidt GA. Sodium bicarbonate for the treatment of lactic acidosis. Chest. 2000 Jan;117(1):260-7. doi: 10.1378/chest.117.1.260. PMID: 10631227. 2. Waskowski J, Hess B, Cioccari L, Irincheeva I, Pfortmueller CA, Schefold JC. Effects of sodium bicarbonate infusion on mortality in medicalsurgical ICU patients with metabolic acidosis-A single-center propensity score matched analysis. Med Intensiva (Engl Ed). 2021 Jun 10:S02105691(21)00106-6. English, Spanish. doi: 10.1016/j.medin.2021.04.010. Epub ahead of print. PMID: 34120787. 3. Zhang Z, Zhu C, Mo L, Hong Y. Effectiveness of sodium bicarbonate infusion on mortality in septic patients with metabolic acidosis. Intensive Care Med. 2018 Nov;44(11):1888-1895. doi: 10.1007/s00134-018-5379-2. Epub 2018 Sep 25. PMID: 30255318.

CRITICAL CARE MEDICINE SECTION

4. Huang S, Yang B, Peng Y, Xing Q, Wang L, Wang J, Zhou X, Yao Y, Chen L, Feng C. Clinical effectiveness of sodium bicarbonate therapy on mortality for septic patients with acute moderate lactic acidosis. Front Pharmacol. 2023 Jan 9;13:1059285. doi: 10.3389/fphar.2022.1059285. PMID: 36699087; PMCID: PMC9868412. 5. Fujii T, Udy AA, Nichol A, Bellomo R, Deane AM, El-Khawas K, Thummaporn N, Serpa Neto A, Bergin H, Short-Burchell R, Chen CM, Cheng KH, Cheng KC, Chia C, Chiang FF, Chou NK, Fazio T, Fu PK, Ge V, Hayashi Y, Holmes J, Hu TY, Huang SF, Iguchi N, Jones SL, Karumai T, Katayama S, Ku SC, Lai CL, Lee BJ, Liaw WJ, Ong CTW, Paxton L, Peppin C, Roodenburg O, Saito S, Santamaria JD, Shehabi Y, Tanaka A, Tiruvoipati R, Tsai HE, Wang AY, Wang CY, Yeh YC, Yu CJ, Yuan KC; SODA-BIC investigators. Incidence and management of metabolic acidosis with sodium bicarbonate in the ICU: An international observational study. Crit Care. 2021 Feb 2;25(1):45. doi: 10.1186/s13054020-03431-2. PMID: 33531020; PMCID: PMC7851901.

6. Cooper DJ, Walley KR, Wiggs BR, Russell JA. Bicarbonate does not improve hemodynamics in critically ill patients who have lactic acidosis. A prospective, controlled clinical study. Ann Intern Med. 1990 Apr 1;112(7):492-8. doi: 10.7326/0003-4819-112-7-492. PMID: 2156475. 7. Mathieu D, Neviere R, Billard V, Fleyfel M, Wattel F. Effects of bicarbonate therapy on hemodynamics and tissue oxygenation in patients with lactic acidosis: a prospective, controlled clinical study. Crit Care Med. 1991 Nov;19(11):1352-6. doi: 10.1097/00003246-199111000-00008. PMID: 1935152. 8. Jaber S, Paugam C, Futier E, Lefrant JY, Lasocki S, Lescot T, Pottecher J, Demoule A, Ferrandière M, Asehnoune K, Dellamonica J, Velly L, Abback PS, de Jong A, Brunot V, Belafia F, Roquilly A, Chanques G, Muller L, Constantin JM, Bertet H, Klouche K, Molinari N, Jung B; BICAR-ICU Study Group. Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomised controlled, phase 3 trial. Lancet. 2018 Jul 7;392(10141):31-40. doi: 10.1016/S0140-6736(18)31080-8. Epub 2018 Jun 14. Erratum in: Lancet. 2018 Dec 8;392(10163):2440. PMID: 29910040.

JUSTICE, EQUITY, DIVERSITY, AND INCLUSION SECTION

Countinued from page 27

With the rapid increase of the LGBTQ+ population, including 20% of younger generations, we need to be proactive in the recruitment of queer physicians to reflect our patient demographics. This helps ensure a workplace of cultural competencies, minimal bias, optimized patient care, and

improved outcomes. As emergency medicine physicians, we encounter and celebrate diversity on a daily basis. All we need to do now is expand the definition of it.

References 1. Jones, J. M. (2022, February 17). LGBT identification in U.S. ticks up to 7.1%. Gallup.com. https://news.gallup.com/poll/389792/lgbt-identificationticks-up.aspx 2. Lien K, Vujcic B, Ng V. Attitudes, behaviour, and comfort of Canadian emergency medicine residents and physicians in caring for 2SLGBTQI+ patients. CJEM. 2021 Sep;23(5):617-625. doi: 10.1007/ s43678-021-00160-5. Epub 2021 Aug 7. PMID: 34363194. 3. Gisondi, M.A., Bigham, B. LGBTQ + health: a failure of medical education. Can J Emerg Med 23, 577–578 (2021). https://doi.org/10.1007/s43678021-00185-w

4. Seelman KL, Colón-Diaz MJP, LeCroix RH, Xavier-Brier M, Kattari L. Transgender Noninclusive Healthcare and Delaying Care Because of Fear: Connections to General Health and Mental Health Among Transgender Adults. Transgend Health. 2017 Feb 1;2(1):17-28. doi: 10.1089/trgh.2016.0024. PMID: 28861545; PMCID: PMC5436369. 5. Underrepresented in medicine definition. Association of American Medical Colleges. Accessed January 15, 2021. https://www.aamc.org/what-we-do/ diversity-inclusion/underrepresented-in-medicine

COMMON SENSE NOVEMBER/DECEMBER 2023

IN-DEPTH EDUCATION FOCUSED ON YOUR SPECIALTY. Register at sitcancer.org/aci | #LearnACI

CLINICAL EDUCATION PROGRAMS FOR EMERGENCY PHYSICIANS SITC’s Advances in Cancer Immunotherapy™ (ACI) programs offer focused clinical education on a disease state or topic at no cost to the emergency care team. Attendees of these innovative programs get in-depth training in immunotherapy treatment that can be directly applied to patients in emergency care.

2023 PROGRAMS

Scan or visit sitcancer.org/aci to learn more & register

ACI: Online Courses

The ACI 2023 interactive eLearning modules are designed to cover the foundational and basic immunology principles and the mechanisms and clinical applications of immunotherapy.

2023 ACI: Introduction to Biomarkers 2023 ACI: Mechanisms of Immune-related Adverse Events (irAEs) 2023 ACI: Introduction to Immunology 2023 ACI: Basic Principles of Cancer Immunotherapy 2023 ACI: Combination Therapies in Combating Cancer 2023 ACI: irAEs Associated with Cellular Therapies and T-cell Engagers

Understand basic immunology and immunotherapy principles and mechanisms with CE and MOC-certified online courses from SITC's ACI series. Gain an in-depth understanding of how irAEs function and the key biomarkers in immunotherapy treatment while earning CE and MOC credits.

FREE FOR HEALTHCARE PROFESSIONALS, STUDENTS, PATIENTS AND PATIENT ADVOCATES. CME, CNE, CPE AND MOC CREDITS AVAILABLE. The 2023 ACI series is jointly provided by the Partners for Advancing Clinical Education and the Society for Immunotherapy of Cancer in collaboration with the Association of Community Cancer Centers, the Advanced Practitioner Society for Hematology and Oncology and the Hematology/Oncology Pharmacy Association. These programs are provided in collaboration with the American Academy of Emergency Medicine.

The 2023 Advances in Cancer Immunotherapy™ educational series is supported, in part, through independent medical education grants from AstraZeneca, Bristol Myers Squibb, Exelixis, GSK, Merck Sharp & Dohme, Corp., a subsidiary of Merck & Co., Inc. (MSD) and Novartis Pharmaceuticals Corporation. 36

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THE WHOLE PHYSICIAN

May I Have Your Attention Please? Amanda Dinsmore, MD FAAEM, Laura Cazier, MD FAAEM, and Kendra Morrison, DO

about what’s going right with the patient? We need to figure out the must-not-miss diagnosis that could harm the patient, no matter how unlikely it is.

magine you’re at a cocktail party and you hear every single word spoken, every clink of the silverware, every musical note and lyric from the background music. You smell every waft of food and cologne, every single sensory signal is pouring into your brain. It would quickly be overwhelming. You’d have a very hard time having a conversation with the person next to you. Human brains have an amazing solution for this: selective attention. Verywellmind says, “selective attention is the process of focusing on a particular object in the environment for a certain period of time. Attention is a limited resource, so selective attention allows us to tune out unimportant details and focus on what matters.”1 It’s like a camera lens to bring the subject into focus and blur out the rest, so it’s unrecognizable.

Mental filtering is closely related to another thought error called discounting the positive. This is where we ignore or discount the good things that happen.3 How many patients have you given yourself credit for helping? Many of us shrug it off as part of the job. So it becomes clear that, unfortunately, the very same highly tuned part of our brain that makes us great doctors makes us miserable if we don’t intentionally shut it off outside of work. Consider what the “camera” is focusing on is only one tiny part of the whole. The world is both terrible and amazing. A person might be sick with pneumonia, but her heart is still pumping, and her brain is still sharp. Your spouse might be super annoying and the best thing that’s ever happened to you. Why does your focus matter anyway? It matters because your feelings are determined by your thoughts, not the circumstances of your life. This is the basis of the Cognitive Thought Model.4 So it isn’t the facts of your life, it’s the thoughts about those facts that lead you to feel a certain way. The actions you take in your life are driven by the feelings you’re experiencing. Having hyperfocus on the negative leads to feeling pretty crummy a lot of the time. Feeling pretty crummy leads to actions that tend to just reinforce the negativity.

When your brain is focused on all of the bad that’s all it will see.

There is a famous “invisible gorilla” experiment by Daniel Simons and Christopher Chabris where subjects are tasked with counting the times a ball is passed between people wearing white shirts on a video. There also happens to be people passing a ball in black shirts for added distraction. Midway through the video, a person dressed in a gorilla suit walks through the screen, and the vast majority of people are so focused on the white shirted ball-passers that they completely miss it. Selective attention is amazing—otherwise we’d be rendered incapacitated with sensory input. But for many of us, the selection our “camera” is focusing on in daily life is left unchecked, to our detriment.

Mental filtering “is the tendency to ignore positives and focus exclusively on negatives.”2 A negativity bias is a human tendency. Up until modern times, life was quite perilous. Survival was top priority, certainly overindulgences such as happiness. It makes sense that our brains should be finely tuned to pick out the blip on the horizon that might spell danger, ignoring the rest. Think about how useful this is in medicine. Who cares

For example, many patients in the ED exemplify societal ills. At one point in my career, because of mental filtering, I found myself assuming the dysfunction I saw at work was representative of the majority of society. I’d imperceptibly think to myself, “people (out there) are messy.” This led to isolating myself more, looking for the bad in others, and not making attempts to form new connections and acquaintances. Avoiding getting to know people better and being hypervigilant of flaws only made it easier to believe my thought that people are messy. Because guess what. They are. But they’re also delightful, fun, surprising, loving, entertaining, and wonderful. And once I started challenging my automatic negative thoughts, I was delighted to find wonderful new connections in addition to the ones I already had. >> COMMON SENSE NOVEMBER/DECEMBER 2023

THE WHOLE PHYSICIAN

So consider changing perspective, or “reframing.” In the words of George Lucas, “always remember, your focus determines your reality.” Tony Robbins says it other ways: “your life is controlled by what you focus on,” and “energy flows where attention goes.” When your brain is focused on all of the bad that’s all it will see. It’s self-fulfilling because it will blur out anything that contradicts the selected filter. Reframing or Changing Perspective

It makes sense that our brains should be finely tuned to pick out the blip on the horizon that might spell danger, ignoring the rest. Think about how useful this is in medicine. Who cares about what’s going right with the patient? We need to figure out the must-not-miss diagnosis that could harm the patient.

Challenging how negative everything is isn’t gaslighting yourself, it’s merely changing the majority input of your life, similar to changing the TV show you’re watching. On purpose. Both the negative and positive continue to exist, it’s merely changing the lens aperture of your “camera” and refocusing on a more useful subject matter. One that adds positively to your life. Some tips: •

•

Challenge your point of view. Any time you find yourself stuck thinking only about the negative, give equal air time to the opposite. Ask yourself, is this 100% true? Is it possible there is another perspective? Is this serving me in any way to keep thinking this? What if this works out great after all? Am I thinking all-or-nothing or is there some way to give partial credit? Validate Emotions. We aren’t suggesting toxic positivity. There are bad things in the world. It would be weird to be excited and joyful about them. But staying stuck in negative emotion most of the time isn’t usually necessary or particularly helpful. Part of the human experience is to experience negative emotions but allow them without judgment. Let them pass rather than pushing them away. Otherwise, it denies your humanity. Show compassion. Want to know who gets the brunt of our mental filtering and dismissing the positive? Ourselves. And the thoughts about ourselves are the ones we can’t escape. If the voice in your head says things to you that you’d never say to someone else, it’s time to work on that. Developing positive self-talk is key. You are enough. Your worth as a human isn’t determined by your flawlessness. Malcolm Forbes is credited with saying “too many people overvalue what they are not and undervalue what they are.”

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Consider a much better use of your time. Instead of solely focusing on the obstacles and problems in the world, focus on the solutions. Napoleon Hill says, “focus on the possibilities for success, not on the potential for failure.” They’re both imaginary anyway, but one moves you forward and feels so much better. Intentionally focusing on what’s possible and what’s right with the world harnesses the power of your brain for action and success, the other holds you back. We each only have a limited amount of mental energy each day, so use it wisely. This is why a gratitude practice is not “woo.” Each moment you spend in gratitude, you challenge the negativity bias in your brain. And it feels great. When you feel great, you do great things for yourself and others. Editor’s Note: This “The Whole Physician” article was intended for the September/October issue of Common Sense. We apologize for this omission. thewholephysician.com References 1. https://www.verywellmind.com/what-is-selective-attention-2795022 2. https://www.healthline.com/health/cognitive-distortions#mental-filtering 3. https://www.verywellmind.com/reframing-defined-2610419 4. https://journals.sagepub.com/doi/pdf/10.1177/1755738012471029

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Early Rhythm-Control Versus Rate-Control in Atrial Fibrillation: A Settled Debate? Authors: Victoria Zaccone, MD, Wesley Chan, MD, Christopher Kiang, MD, and Michelle Chen, DO Editors: Donald Doukas, MD and Kami M. Hu, MD FAAEM

Introduction

Atrial fibrillation (AF) is the most common sustained arrhythmia in adults, associated with significant morbidity, mortality, and healthcare burden. It can be difficult to manage, with AF treatment including both rate- and rhythm-control methods, but which is better? Treatment has historically focused on ventricular rate-control, as supported by decades-old randomized controlled trials which helped pave the way for current clinical practice. With the advent of new antiarrhythmic drugs and more sophisticated options for ablation, however, it is worth revisiting the literature to consider the benefits of early rhythm control (ERC). Our review examines the current literature on AF treatment and the emerging role of ERC. Clinical Question: Is rhythm control superior to rate control in reducing cardiovascular comorbidities in atrial fibrillation? Wyse DG, Waldo AL, DiMrarco JP, et al; Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347(23):1825-33.

The 2002 AFFIRM trial was a multicenter, parallel-group, randomized controlled trial. Four thousand patients with nonvalvular AF were enrolled across 213 clinical sites and followed for a median time of 3.5 years. The study included patients who were 65 years old with atrial fibrillation that was likely to be recurrent, with high risk of stroke or death requiring long term AF treatment. Patients with contraindications to anticoagulation therapy or who were unable to undergo trials of two or more medications were excluded. The patients were grouped into two treatment strategy arms: rate control and rhythm control. The rate-control arm could be managed with class II (beta-blockers), class IV (calcium channel blockers), or class V (digoxin) agents for a therapeutic target heart rate of less than 80 beats per minute (bpm) at rest and less than 110 bpm during activity. These patients were anticoagulated with warfarin to a goal international normalized ratio (INR) of 2-3. The rhythm-control arm could use class 1a (quinidine, procainamide, diisopyramide), class 1c (flecainide, propafenone, moricizine) and class III agents (amiodarone, sotalol, dofetilide), as well as cardioversion as needed to maintain sinus rhythm. Anticoagulation with warfarin in this group was encouraged but could be stopped at the treating physician’s discretion if sinus rhythm maintained for at least four, although preferably 12, consecutive weeks. The two groups were similar in terms of baseline characteristics, with an overall average age of 70 years, approximately 40% women, and 89% white ethnicity. Hypertension and coronary artery disease were the top two primary cardiac diagnoses, at 50% and 25%, respectively. There was no significant difference between the two groups in terms of

the primary outcome of five-year mortality (25.9% vs. 26.7%; HR=0.87, 95% CI 0.75 to 1.01), although the authors noted the non-significant trend toward a mortality benefit, particularly those aged ≥65 and those without a history of heart failure (HF). There was a lower incidence of hospitalizations (73% vs. 80.1%, p<0.001), Torsades de pointes (0.2% vs 0.8%, p=0.007), and PEA or bradycardic cardiac arrest (<0.1% vs. 0.6%, p=0.01) in the rate-control group, and fewer adverse drug effects associated as well. Some limitations include possible selection bias, as patients with frequent or severe symptoms might have been considered unsuitable for a rate-control strategy. With the inclusion of paroxysmal AF, there was a relatively high prevalence of sinus rhythm, even in the rate-control group, and there was also crossover between the two groups (up to 15% after five years). The authors acknowledged that the results are not generalizable to younger patients or patients without risk factors for stroke, including those with paroxysmal AF. In addition, those with successful rhythm control could have their anticoagulation stopped, which could have affected stroke and death outcomes. All in all, as one of the first randomized controlled trials providing evidence favoring rate control, the AFFIRM trial helped to pave the way for current clinical practice. Camm AJ, Breithardt G, Crijns H, et al. Real-life observations of clinical outcomes with rhythmand rate-control therapies for atrial fibrillation RECORDAF (Registry on Cardiac Rhythm Disorders Assessing the Control of Atrial Fibrillation). J Am Coll Cardiol. 2011;58(5):493-501.

The RECORDAF survey was the first to examine real-world therapeutic successes and clinical outcomes associated with rhythm-control and rate-control strategies. It was a large-scale prospective, observational study that included 5,604 patients across 21 countries, primarily examining the outcomes of rhythmversus rate-controlled groups over one year. Inclusion criteria included age over 18-years old, a recent diagnosis of AF within one year, and eligibility for pharmacologic treatment. Permanent or reversible AF patients were excluded. A propensity score for each group was calculated, factoring in demographics and characteristics of AF such as classification, duration, symptoms, and family history. It also took into consideration important comorbidities such as history of myocardial infarction, valvular disease, diabetes, dyslipidemia, carotid stenosis, and HF. Primary endpoints included therapeutic success, defined as presence of sinus rhythm for the rhythm-control group or a heart rate of 80 bpm or less for the rate-control group, not requiring a change in the strategy from baseline, and occurrence of clinical outcome events. Clinical outcome events were further defined as cardiovascular death up until 15 months, stroke or TIA requiring hospitalization, hospitalizations >> COMMON SENSE NOVEMBER/DECEMBER 2023

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related to arrhythmic events or ablation complications, and any other cardiovascular event (HF, unstable angina, percutaneous coronary intervention, peripheral vascular disease, valvular surgery, coronary artery bypass grafting) or other cardiovascular surgeries. Secondary endpoints included assessment of AF control, proportion of patients in sinus rhythm, treatment modalities and adverse reactions to AF treatment. At baseline, those in the rate-control group tended to have a higher risk patient profile with significant cardiac comorbidities and more often presented with persistent AF, compared with the rhythm-controlled group, who were younger, more frequently symptomatic, and more likely to have recent-onset or paroxysmal AF. At one-year follow-up, 81% of the rhythm-control group was in sinus rhythm, compared to 33% of the rate-control group, with development of permanent AF in 13% of the rhythmversus 54% of the rate-control group (permanent AF progression OR 0.20, 95% CI 0.17-0.25, p<0.0001). After multivariable analysis, adjusting for baseline differences, the authors found that a rhythm-control strategy significantly increased the chance of therapeutic success at one year (OR 1.67, 95% CI 1.45-1.91, p<0.0001), as did the absence of CAD, HF, age ≤ 75, and lack of TIA/stroke history. After similar analysis, they determined that a rhythm-control strategy did not affect rate of clinical outcome events. There are a few limitations and criticisms to RECORDAF. For one, the patient population between groups was vastly different, with comparisons relying on multivariable statistical analysis. It was also discovered that while clinical treatment guidelines exist, many treating physicians were actually already utilizing a combination of rate-and rhythm-control methods, posing challenges in patient grouping and data interpretation. It is worth noting that the rhythm-control group’s success was determined based on a single ECG showing sinus rhythm at the end of one year, although interestingly, the success rate (81%) paralleled the success seen in the AFFIRM trial. Finally, the significantly-higher therapeutic success rate seen with the rhythm-control group was noted by authors to be largely due to the failure of initial therapy in the rate-control group. The RECORDAF findings support the concept that clinical outcomes have more to do with a patient’s personal risk factors and symptom burden than with treatment using one specific strategy, and that rhythm-control strategies are associated with less progression to permanent AF, leading the authors to still suggest that rhythm-control may be the superior therapy. Kirchhof P, Camm AJ, Goette A, et al.; EASTAFNET 4 Trial Investigators. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med. 2020;383(14):1305-1316.

This international, investigator-initiated, randomized trial re-examined outcomes associated with an ERC strategy as compared to usual care, defined as a rate-control strategy without rhythm-control therapies. The study population included adults ≥18 years of age with AF diagnosed ≤12 months before enrollment with a median time of treatment from

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diagnosis of 36 days. Participants also needed to meet one of the three high-risk features, including age ≥75 years, prior TIA or stroke, or two of the following: ≥65 years of age, female sex, heart failure, hypertension, diabetes mellitus, severe coronary artery disease, chronic kidney disease, and left ventricular hypertrophy. The first primary outcome was a composite outcome of death from cardiovascular causes, stroke, or hospitalization with worsening heart failure or acute coronary syndrome. The second primary outcome was the number of nights spent in the hospital per year. A total of 2789 eligible patients underwent randomization to either usual care (1394 patients) or ERC (1395 patients). Most patients (94.8%) in the ERC group were managed early on with either an antiarrhythmic drug or AF ablation. At two years, 19.4% of patients in the ERC group had undergone AF ablation and 65% were still receiving antiarrhythmic medications, while approximately 15% of usual care patients were receiving antiarrhythmic therapies. The trial was stopped for efficacy after a median of 5.1 years, finding that treatment with rhythm control within 12 months of AF diagnosis, compared to usual care, was associated with a modest decrease in the composite primary outcome, over a follow-up time of about five years (absolute difference in risk, 1.1 events per 100 person-years; HR=0.79, 96% CI 0.66 to 0.94; P=0.05). This finding remained consistent in subgroup analyses and after adjusting for relevant covariates. There was a decreased incidence of stroke in the ERC group (2.9% vs. 4.4%, p=0.03), with more serious adverse events related to therapy (4.9 vs. 1.4, p<0.001). There was no significant difference in the mean number of hospital nights between the two groups at two years. Limitations include the open-trial study design, which the authors tried to mitigate by using a blinded-outcome-assessment design. Additionally, the results may not be generalizable to patients with AF longer than 12 months, or whose access to care does not include regular cardiology appointments with strict management according to cardiovascular society guidelines. This study cannot address any question comparing use of antiarrhythmic medications with or without catheter ablation. Prior trials have mentioned the adverse side effects of antiarrhythmic drugs as a major barrier to its utility. Approximately one third (34.9%) of patients in the ERC group were not receiving any antiarrhythmic therapies after two years. It is unclear whether this was due to adverse effects of antiarrhythmic therapy, withdrawal from the study, loss to follow up or because antiarrhythmics were deemed to be no longer necessary. The paper also makes little mention of the AF symptom burden for its study population. Unlike prior major trials examining rate versus rhythm control, the results from the EAST-AFNET4 study favor the use of ERC. The authors mention that the use of catheter ablation may have contributed significantly to their differing outcomes as earlier studies including the RACE and AFFIRM trials were conducted prior to the widespread use of catheter ablation. They also emphasized that ERC potentially demonstrated more >>

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benefit in the management of these early AF patients compared to trials evaluating rhythm control in long-established AF; the longer AF persists, the less likely the heart will maintain sinus rhythm after cardioversion.1-2 Kim D, Yang PS, You SC, et al. Treatment timing and the effects of rhythm control strategy in patients with atrial fibrillation: nationwide cohort study. BMJ. 2021;373:n991.

This study sought to evaluate the EAST-AFNET 4 trial’s suggestion that timing of therapy affected efficacy and outcomes with use of a rhythmversus rate-control strategy in AF management. A retrospective analysis based on claims in the National Health Insurance Service (NHIS) of Korea, it evaluated patients with a new diagnosis of AF between July 28, 2011, and December 31, 2015. Patients included were those high-risk for cardiovascular outcomes, as defined in the EAST-AFNET 4 trial. Patients who were not on anticoagulation or died within 180 days of initiating therapy were excluded from the study. The investigators compared rhythmversus rate-control strategies across early versus late treatment groups. Early treatment was defined as initiation of AF management within one year of diagnosis while late treatment was defined as initiation of AF treatment after one year. They adopted the EAST-AFNET 4 trial primary endpoints: a composite of death from cardiovascular causes, ischemic stroke, hospital admission due to heart failure, and acute myocardial infarction as well as the number of nights spent in the hospital each year. A total of 22,635 patients were included, with 16,323 in the early intervention group (9246 rhythm-control, 7077 rate-control) and 6312 in the late intervention group (4407 rhythm-control, 1905 rate-control). Approximately 53.9% were male. Treatment was started after a mean of one month after AF diagnosis in the early group, and a mean of 69.5 months in the late treatment group. Ablation was used more often in the late treatment cohort, both as an initial rhythm control strategy (1.6% early vs. 14.5% late) and overall (6.9% early vs. 19.6% late). In the early treatment group, rhythm-control was associated with a decrease in the primary composite outcome compared to rate-control (7.42 vs. 9.25 events per 100 person years; HR 0.81, 95% CI 0.71-0.93, p=0.002), with lower individual risk of stroke and heart failure admissions, as well as fewer average nights spent in the hospital per year (26.1 vs. 30.4, p<0.001). There were no significant differences in the primary composite safety outcome. In the late treatment group, no primary or safety outcome differences were noted between the rhythm- and rate-control treatment arms (8.67 vs. 8.99 events per 100 person years; HR 0.97, 95% CI 0.78-1.20, p=0.76). While the study removed selection bias by including the population of South Korea in their study and proposed a new way to mimic a randomized control trial, there are several shortcomings. The authors used ICD10 codes, which do not allow for evaluation of disease burden,

incorrect coding, or understanding clinical decision-making between rhythm- and rate-control strategies. As a retrospective database review, authors could not completely prevent further confounding variables, assess lifestyle modifications, or undiagnosed disease that may have affected the data. Of note, while ablation for rhythm is a tool that can be more readily used in the USA, South Korea has strict guidelines that require a person to be intolerant to conventional treatment, such as tachycardia-bradycardia syndrome, and requires more than six weeks of antiarrhythmic treatment before the procedure will be approved. Also noteworthy is the significant difference in duration of AF prior to initiation of therapy in the late treatment group and the remaining questions as to why initiation of therapy, whether rate- or rhythm-targeted, started at an average of over five years in this cohort. Overall, initiation of ERC within one year of a new AF diagnosis appeared to be associated with more favorable cardiovascular outcomes when applied in the real-world setting, with a reduced risk of major cardiovascular events when compared to rate control (absolute decrease in risk 1.82 events per 100 person years). The authors concluded that the EAST-AFNET 4 study’s results are likely attributed to earlier initiation of treatment maximizing the efficacy of a rhythm-control strategy, and go on to suggest the possibility of screening asymptomatic individuals in the future. Conclusion

The AFFIRM trial was a landmark trial favoring a rate-control strategy, which helped pave the way for current clinical practice. Studies are beginning, however, to show a trend in favor of early ERC, with potential benefits including reducing irreversible atrial remodeling and preventing cardiovascular comorbidity. While one treatment strategy is not yet formally recommended over the other for all patients, clinicians should begin deploying early rhythm-control strategies depending on the individual patient’s risk factors to optimize favorable cardiovascular outcomes. Clinical Question: Is rhythm control superior to rate control in reducing cardiovascular comorbidities in atrial fibrillation?

Answer: In the emergency department, there is no evidence that rate- or rhythm-control is superior in AF management. It is vital, however, that patients with newly-diagnosed AF be connected to early cardiology follow-up so they can reap the benefits of early multimodal AF treatment strategies. Additional References 1. Abu-El-Haija B, Giudici MC. Predictors of long-term maintenance of normal sinus rhythm after successful electrical cardioversion. Clin Cardiol. 2014;37(6):381-5. 2. Andrade J, Khairy P, Dobrev D, Nattel S. The clinical profile and pathophysiology of atrial fibrillation. Circ Research. 2014;114(9):1453–68.

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AAEM Job Bank Service

Promote Your Open Position

To place an ad in the Job Bank:

Equitable positions consistent with the Mission Statement of the American Academy of Emergency Medicine and absent of restrictive covenants, will be published (upon approval). All ads run for a six month period or until canceled and will appear in the AAEM member magazine Common Sense and online. For pricing and more information visit www.aaem.org/membership/benefits/ job-bank. Complete a Job Bank registration form, along with the Criteria for Advertising Section, and submit payment. If you are an outside recruiting agent, the Job Bank Criteria for Advertising must be downloaded and completed by a representative from the recruiting hospital/group. Direct all inquiries to: www.aaem.org/membership/benefits/job-bank or email info@aaem.org.

Positions Available For further information on a particular listing, please use the contact information listed. Section I: Positions listed in Section I are in compliance with elements AAEM deems essential to advertising in our job bank. Fairness practices include democratic and equitable work environments, due process, no post contractual restrictions, no lay ownership, and no restrictions on residency training and have been given the AAEM Certificate of Workplace Fairness. Section II: Positions listed in Section II are in compliance with elements AAEM deems essential to advertising in our job bank. Fairness practices include democratic and equitable work environments, due process, no post contractual restrictions, no lay ownership, and no restrictions on residency training but have not been given the AAEM Certificate of Workplace Fairness. Section III: Positions listed in Section III are hospital, non-profit or medical school employed positions, military/government employed positions, or an independent contractor position and therefore cannot be in complete compliance with AAEM workplace fairness practices.

SECTION I: POSITIONS RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK CRITERIA AND GIVEN THE AAEM CERTIFICATE OF WORKPLACE FAIRNESS COLORADO

Southern Colorado Emergency Medical Associates (SCEMA) is hiring full time and part time emergency medicine physicians. Must be BC/BE in emergency medicine. We are looking for hard-working team players to join our group. SCEMA is a rare, democratic group of over 30 years based in Southern Colorado with a 2-year partnership track. Come live and work in the beautiful Front Range of Colorado. We offer a superior financial package including a competitive hourly compensation pre-partnership with initial hiring range of 230K-280K and partnership income based on productivity. Partners average over $370k/yr, plus additional benefits valued over $70k/yr including 13% profit sharing in a 401k, a SCEMA funded cash balance plan, $6k/yr CME, and productivity bonuses. Full time

status only requires approximately 14 shifts/month, 8-10 hours shifts, between two facilities based in Pueblo, CO associated with Parkview Medical Center. Please email Dr. Whitney at mcwhit515@gmail.com for further information. (PA 2011) Email: mkodonnell7@gmail.com

VIRGINIA

DEMOCRATIC GROUP TOP TIER COMPENSATION EQUAL PARTNERSHIP Fredericksburg Emergency Medical Alliance (FEMA) in Fredericksburg, Virginia. We are a small democratic group located an hour south of Washington DC currently staffing 3 EDs in the Mary Washington Health Care system. We are looking to hire several new partners after a couple of

recent retirements and the addition of a new freestanding ED, anticipated opening in 2024. Mary Washington ED is a level 2 trauma center with annual volumes of ~65k. Stafford is a community hospital ED that sees ~40k. Our Lee’s Hill FSED is on track to see ~35k this year. We use EPIC EMR, are supported by FEMA-employed APPs and scribes, and offer equitable scheduling from day one. We operate under a fee for service payment model. Top tier compensation. Please upload CVs to www.femainc.com or send directly to Cheema.samia1@gmail. com Feel free to reach out if you have any questions! (PA 2005) Email: aalvarezfema@gmail.com Website: https://www.femainc.com/

SECTION II: POSITIONS RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK CRITERIA CALIFORNIA

Join our team in the San Francisco Bay Area with immediate and ongoing Emergency Medicine and Urgent Care positions! Recently awarded a 5-year contract with an option for a 5-year extension with Santa Clara County Health System. Emergency Physicians Associates (EPA) is a democratic group with absolutely zero private equity, public debt, venture capital involvement, or non-physician shareholders. Pay is productivity based. Average EP hourly in excess of $300.00/hour. Night shift stipend. Transparent 3-year partnership track. Scheduling is performed by a practicing Emergency Physician with a full understanding of typical ED scheduling patterns. Predominantly 9-hour shifts. Engaged and responsive ED leadership. Excellent relationships with hospital administration and nursing staff. EDs we staff: Santa Clara Valley Medical Center. High acuity county hospital. Level 1 trauma center. Regional burn center. STEMI and Stroke receiving center. EM residency host. O’Connor Hospital. Full-service county-owned community hospital. Saint Louise Regional Hospital. Rural county-owned community hospital. Currently in the planning stages for trauma designation. Onsite CalStar base for ease of transfer. Washington Hospital. Busy well, resourced full-service district-owned community hospital in Fremont, CA. Epic EMR at all facilities. Start date ASAP. Ongoing. Full-time or per-diem. Requirements: ABEM BC/BE, unrestricted CA License, unrestricted DEA. Contact EPA at careers@epamg.com with questions and to apply. (PA 1999) Email: daniel.nelson@epamg.com

CALIFORNIA

California Rare Northern California partnership opportunity. We are members of AAEM-PG! We are Mountain Medicine P.C. in Yreka, California. We staff a beautiful ED with everything that you could want as an emergency physician. We are a level 4 trauma center seeing about 12,500 patient per year with APP coverage. Short, transparent partnership track. $275 per hour. Yreka is situated in the Shasta Valley & surrounded by the Klamath Mountains. Small town feel, relaxed lifestyle and one of the most affordable places to live in California. Alpine living with hiking, fishing and camping right outside of your doorstep as well as some of the nation’s best backcountry skiing and mountaineering. Live in nearby Mount Shasta, a spiritual and outdoor recreation mecca, or in Ashland, Oregon, an academic and cultural hub hosting Southern Oregon University and The Oregon Shakespeare Festival. Opportunities abound! Contact: recruitment@ruralpacmed.com (PA 2022) Email: recruitment@ruralpacmed.com

CALIFORNIA

Join our independent, democratic, partnership Group in sunny southern California. Epic, Dragon, holiday and night shift differential as well as APP help. Please send CV in confidence or see our website https://www.scemg.org/ (PA 1994) Email: smistry007@yahoo.com Website: https://www.scemg.org/

COLORADO

CarePoint Health is seeking Full Time Emergency Physicians to join their team in Denver, Colorado. CarePoint is an independent democratic physician-owned and led practice. We have no outside investors or debt and have over 300 equal physician owners. We staff six busy Denver Metro Emergency Departments and seven Freestanding Emergency Departments. We offer a highly competitive incentive/benefits package, and a three year partnership track. Apply to learn more! (PA 2030) Email: hduncan@carepointhc.com Website: https://carepointhc.com/

IDAHO

Full-time opportunity available within the EPIC TVI Division at West Valley Medical Center. West Valley Medical Center is a 27k visit ED with 12-hour single covered shifts and 30 hours of overlapping APP coverage M-F and 20 hours of APP coverage Sat and Sun. West Valley Medical Center is located in Caldwell, Idaho (Boise is 20 minutes away). Annual volume of approximately 27,000. Daily volume averages approximately 74. Admission rate of approximately 13%. Associate rate starts at $200/hour. This is a 2-year partnership position with benefits. (PA 2028) Email: hduncan@carepointhc.com Website: https://carepointhc.com/

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SECTION II: POSITIONS NOT RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK ADVERTISING CRITERIA (Below are hospitals, non-profit or medical school employed positions.)

KANSAS

CarePoint Health is seeking well-trained emergency physicians to join our practice in Wichita, Kansas. Our team is responsible for covering four Emergency Departments in Wichita, including Wesley Medical Center: A Level I Trauma Center. Completion of an ACGME accredited emergency medicine residency is required. New graduate emergency medicine physicians and Visa applicants are encouraged to apply. The Wall Street Journal just ranked Wichita a top place to live based on its affordable cost of living, excellent housing opportunities, excellent job market, wonderful cultural opportunities, and a strong community spirit. (PA 2029) Email: hduncan@carepointhc.com Website: https://carepointhc.com/

KENTUCKY

Full-time Emergency Department physician positions available summer of 2024. Looking for emergency medicine residency trained physicians ABEM eligible or certified. Compass Emergency Physicians is a democratic group located in Northern Kentucky. We staff the six hospitals owned by St. Elizabeth Healthcare. Five of the hospitals are in Northern Kentucky and one of the hospitals is in southeastern Indiana. Our group consists of 54 ABEM certified physicians and 40 APPs. (PA 2007) Email: rgeers@compassemergencyphysicians.com Website: http://compassemergencyphysicians.com

OREGON

Northwest Acute Care Specialists, P.C. (NACS) is an independent, democratic emergency medicine group. We are seeking BC/BE Emergency Physicians who are collaborative team players with excellent interpersonal skills. NACS contracts exclusively with Legacy Health to provide emergency medical services in Portland, Oregon and the surrounding areas. We are recruiting for multiple sites with different practice opportunities. Please see our posting for full job description and to apply: https://emnacs.bamboohr.com/careers/26 (PA 2001) Email: aflora@emnacs.com

SECTION III: POSITIONS NOT RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK ADVERTISING CRITERIA CALIFORNIA

EMERGENCY MEDICINE PHYSICIAN San Francisco Bay Area Contra Costa Regional Medical Center in Martinez, CA, is currently looking for a CA-licensed, BC/BE Emergency Medicine Physician for a full-time, benefited position or a 1099 contract position. The schedule is a mix of days and nights (always double coverage). Our Safety-Net hospital offers a 23-bed ER (17 monitored and 6 non-monitored) that sees over 35,000 patients per year. This is an exceptional opportunity to join a supportive, close-knit, mission driven group to serve the community by providing quality care in our safety-net system. We offer flexibility in scheduling, a competitive compensation package and a collaborative environment of care. We are conveniently located in the East San Francisco Bay, with easy access to Lake Tahoe, San Francisco, the Napa Valley, the Sierra Foothills and all coastal areas. For more information, email your CV and cover letter to recruit@cchealth.org. EOE (PA 2023) Email: recruit@cchealth.org

COLORADO

The Department of Emergency Medicine of the Denver Health and Hospital Authority is recruiting a passionate and talented Emergency Physician to serve as Clerkship Director and Assistant Residency Program Director for the Denver Health Residency in Emergency Medicine (DHREM). The Clerkship Director will be responsible for the education of emergency medicine bound medical students at both Denver Health and the University of Colorado School of Medicine, ongoing mentorship for EM-bound students as core EM Specialty-Specific Advisor, and oversight of off-service residents/fellows rotating through the Denver Health emergency department. As an Assistant Residency Director, this position will serve as a core member of the Residency Leadership team, focusing on projects related to health equity and pipeline programs, recruitment, and supporting all educational and academic missions of the residency program. The Denver Health Residency in Emergency Medicine is one of the oldest and most highly regarded Emergency Medicine training programs in the country with a longstanding legacy of training future leaders in our specialty. The department educates over 60 local and visiting emergency-medicine-bound students each year, providing an unparalleled clinical experience with students working at both of our core clinical sites, Denver Health and the University of Colorado Hospital. Students are exposed to our breadth of faculty expertise through didactics, mentorship, and unique educational opportunities focusing on Emergency Medical Service (EMS), Social Emergency Medicine, and Ultrasound. With one of the first funded externships for Underrepresented in Medicine (UiM) Emergency Medicine applicants in the country, our department continues to push opportunities to support and diversify our program and our specialty. With more than 12 fellowship programs across our core institutions, the Department of Emergency Medicine has a deep commitment to educational excellence and scholarship and a robust group of hard-working and committed educators. Applicants should submit CV and cover letter to: Aaron Ortiz, Manager Provider Recruitment aaron.ortiz@dhha.org (PA 2015) Email: aaron.ortiz@dhha.org Website: https://www.denverhealth.org

COLORADO

The Department of Emergency Medicine at Denver Health Medical Center is recruiting a passionate and talented Emergency Physician to serve as Director of Quality and Safety. This position will serve as a core member on our clinical

COMMON SENSE NOVEMBER/DECEMBER 2023

operations team, focusing on setting strategy, implementing initiatives and tracking outcomes related to the quality and safety of the care provided to our patients. The emergency department at Denver Health includes 57 adult beds, 19 pediatric beds, and a separate 23-bed clinical decision unit. With a combined annual census of more than 100,000 patients from highly diverse cultures and backgrounds, the ED at Denver Health is the second busiest in Colorado. The Ernest E Moore MD Shock Trauma Center at Denver Health is the primary trauma referral center for the Rocky Mountain Region. Additionally, the acuity managed by the adult ED is high, with a 25% admission rate. Staffing in the adult and pediatric EDs is provided by board-certified emergency physicians, emergency medicine residents and subspecialty fellows, and advanced practice providers. Strong and extremely collaborative relationships exist among physicians, advanced practice providers, nursing, and consultative services. Denver Health is a large urban health care center that is proud to serve as a primary Anchor Institution to the Denver metro area, and its diverse community. Denver Health is a major academic affiliate of the University of Colorado School of Medicine, based at the University of Colorado Anschutz Medical Campus. All faculty ultimately report to the Director of Service for Emergency Medicine at Denver Health, contributing to our mission of excellence in patient care, education, research, and professional development, and have meaningful responsibilities and faculty appointments in the University of Colorado School of Medicine’s academic Department of Emergency Medicine. Applicants should submit CV and cover letter to: Aaron Ortiz, Manager Provider Recruitment aaron.ortiz@dhha.org (PA 2016) Email: aaron.ortiz@dhha.org Website: https://www.denverhealth.org

COLORADO

The Department of Emergency Medicine at Denver Health Medical Center is recruiting a passionate and talented senior Emergency Physician to serve as Director of Diversity, Equity, Inclusion and Belonging. This position will serve as a core member on our department’s leadership team, developing, implementing, and monitoring outcomes of strategies to enhance our departmental DEIB efforts, institutional including the recruitment, retention, and support of faculty. The emergency department at Denver Health includes 57 adult beds, 19 pediatric beds, and a separate 23-bed clinical decision unit. With a combined annual census of more than 100,000 patients from highly diverse cultures and backgrounds, the ED at Denver Health is the second busiest in Colorado. The Ernest E Moore MD Shock Trauma Center at Denver Health is the primary trauma referral center for the Rocky Mountain Region. Additionally, the acuity managed by the adult ED is high, with a 25% admission rate. Staffing in the adult and pediatric EDs is provided by board-certified emergency physicians, emergency medicine residents and subspecialty fellows, and advanced practice providers. Strong and extremely collaborative relationships exist among physicians, advanced practice providers, nursing, and consultative services. Denver Health is a large urban health care center that is proud to serve as a primary Anchor Institution to the Denver metro area, and its diverse community. Denver Health is a major academic affiliate of the University of Colorado School of Medicine, based at the University of Colorado Anschutz Medical Campus. All faculty ultimately report to the Director of Service for Emergency Medicine at Denver Health, contributing to our mission of excellence in patient care, education, research, and professional development, and have meaningful responsibilities and faculty appointments in the University of Colorado School

of Medicine’s academic Department of Emergency Medicine. Applicants should submit CV and cover letter to: Aaron Ortiz, Manager Provider Recruitment aaron.ortiz@dhha.org (PA 2017) Email: aaron.ortiz@dhha.org Website: https://www.denverhealth.org

CONNECTICUT

Trinity Health Of New England seeks BC/BE EM Physicians to join our emergency medicine teams at Mercy Medical Center in Springfield, Massachusetts, Saint Francis Hospital and Medical Center in Hartford, Connecticut and Saint Mary’s Hospital in Waterbury, Connecticut. Our practice model empowers our physicians to work at their highest level, while allowing time for professional development and family life. Whether you are focused on providing outstanding patient-centered care or driven to grow into a leadership role, you will thrive at Trinity Health Of New England. To learn more, visit our provider portal at www. JoinTrinityNE.org (PA 2024) Email: dhowe@trinityhealthofne.org Website: https://www.jointrinityne.org/Physicians

DELAWARE

ChristianaCare, a recognized leader in healthcare, is seeking Emergency Medicine Physicians. You will be part of a dynamic team covering four state-of-the-art Emergency Departments in Delaware and Maryland. Why ChristianaCare? • The ED’s at ChristianaCare’s Christiana Hospital, Wilmington Hospital, Union Hospital, and the free-standing emergency department in Middletown, Delaware treat a combined total of more than 225,000 patients each year. • Christiana Hospital ranks in the top 25 in the country for emergency visits and is Delaware’s only Level I trauma center that treats adults and children - the only center of its kind between Philadelphia and Baltimore. (PA 2019) Email: megan.hopkins@christianacare.org Website: https://christianacare.org/us/en

FLORIDA

The Schmidt College of Medicine at Florida Atlantic University is seeking an Assistant Program Director to join its Emergency Medicine Residency Program. This position is intended for faculty with experience in teaching, leadership, innovation and clinical service in an emergency medicine residency program. All applicants must apply electronically on the FAU Office of Human Resources’ career website (https://fau.edu/jobs) by completing the required online employment application. When completing the online application, please upload the required cover letter and curriculum vitae. To review the full minimum qualifications and requirements and to apply, visit www.fau.edu/jobs and go to Apply Now (REQ16576). (PA 2010) Email: none@notavailable.com Website: https://fau.wd1.myworkdayjobs.com/en-US/FAU/job/ Clinical---Off-Campus-Location-COM-use-only/AssociateProgram-Director--Emergency-Medicine-Residency--AssistantAssociate-Professor-_REQ16576?q=REQ16576 Louisiana Ochsner Health is seeking board certified/board eligible physicians to join our Division of Pediatric Emergency Medicine at Ochsner Medical Center and Ochsner Hospital for Children. Our opportunity includes an employed physician group that offers competitive fair market compensation plus benefits; an in-house pediatric intensivist and hospitalist attendings 24/7 to assist with streamlined pediatric admissions and patient care; all facilities utilizing Epic electronic health records integrating care across the system and facilitating seamless multi-hospital

SECTION III: POSITIONS NOT RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK ADVERTISING CRITERIA — continued practice; and all specialties available for consultation and easy one-call transfer from our community emergency departments to our main campus. (PA 2033) Email: courtney.lawhun@ochsner.org Website: https://ochsner.wd1.myworkdayjobs.com/ OchsnerPhysician/job/New-Orleans---New-Orleans-Region--Louisiana/Pediatric-Emergency-Medicine_REQ_00158668

MASSACHUSETTS

Emergency Medicine Physician Dartmouth Health The Department of Emergency Medicine at Dartmouth-Hitchcock Medical Center (DHMC) is seeking a BC/BE Emergency Medicine Physician to join our team of dedicated Emergency Physicians. Responsibilities include supervision and teaching of medical students, off-service residents, and Emergency Medicine residents. Interested physicians are encouraged to apply online by submitting their CV and addressing their cover letter to: Scott Rodi, MD, MPH, FACEP Chair, Department of Emergency Medicine Emergency Medicine Regional Medical Director, Dartmouth Health Qualifications • Advanced clinical degree (MD or DO) • Post graduate training in Emergency Medicine residency program Apply link: https://careers. dhproviders.org/emergency-medicine-physician-lebanon-3-0 EOE. (PA 2000) Email: Jacqueline.M.LaBelle@hitchcock.org Website: https://careers.dhproviders.org/emergency-medicinephysician-lebanon-3-0

MINNESOTA

Mayo Clinic is seeking board-certified and board-eligible Emergency Medicine Physicians to join our world-class clinical and academic communities throughout the country. You can choose from opportunities at our large medical centers in Minnesota, Arizona, and Florida, or a community-based practice

within Mayo Clinic Health System locations across Minnesota, Iowa, and Wisconsin. Ranked as the #1 hospital in the nation by U.S. News & World Report in 2022-2023, Mayo Clinic physicians deliver excellence in patient care through active engagement in clinical care, teaching, research, and leadership. A Mayo Clinic Career Offers: •Competitive Compensation •Comprehensive Benefit Package (https://jobs.mayoclinic.org/ benefits) •Funded CME and travel days •Generous Relocation Assistance •Malpractice covered by Mayo Clinic To view and apply to current opportunities, please visit jobs.mayoclinic.org/ emergencymedicine. (PA 2003) Email: hooks.aaron@mayo.edu Website: https://jobs.mayoclinic.org/emergencymedicine

MINNESOTA

Winona Health is seeking a BC/BE EM Physician to join our Emergency Medicine team located in a Midwest college community along the banks of the Mississippi River. • Full-time and part-time, employed positions joining an established team of Physicians, Physician Assistants, nurses and support staff • Full-time and part-time nights or day/night opportunities • Responsible for the acute care of ER patients • 11,000-12,000 visits annually • Level IV trauma and stroke certified facility • Electronic Medical Record, CPOE, patient tracking, bedside US, Dragon • Progressive team of providers committed to quality; evidence-based care, exceptional patient satisfaction; and integrated technology • Competitive hourly compensation & benefits package including sign-on incentive, paid malpractice with tail coverage, $7,500 annual CME & dues/license, moving expenses, health/life/dental insurance, retirement programs and more (PA 2031) Email: dholtzclaw@winonahealth.org Website: http://www.winonahealth.org

NEW JERSEY

RWJBarnabas Health, the largest integrated healthcare system in NJ, is seeking a Pediatric Emergency Medicine Physician for a FT role at Monmouth Medical Center in Long Branch, NJ. As part of the Pediatric Emergency Medicine team, the candidate will work alongside an experienced team of physicians and the opportunity to work closely alongside MMC’s Pediatrics division. In the heart of the Jersey Shore, this practice is just moments away from the famous NJ beaches and shore attractions. Requirements: • BE/BC in Pediatric Emergency Medicine • NJ licensed or eligible If you are interested in this position, contact Meghan.Ryan@rwjbh.org (PA 1997) Email: Meghan.Ryan@rwjbh.org Website: https://www.rwjbh.org/

ONTARIO, CANADA

Located in beautiful Windsor, Ontario, Canada, our client, Windsor Regional Hospital (WRH), is situated directly across the border from Detroit, Michigan. WRH is the regional provider of advanced care in complex trauma, renal dialysis, cardiac care, stroke, neurosurgery, intensive care and acute mental health. WRH is seeking a Chief, Department of Emergency Medicine who will provide strong leadership across the Department and Program for service delivery, resource utilization and metrics driven performance management. CPSO Pathway licensure is easily available for U.S. Board Certified Physicians. Please forward a CV and cover letter in confidence to: Marcy SaxeBraithwaite, E-mail: msaxe-braithwaite@medfall.com (PA 2004) Email: msaxe-braithwaite@medfall.com Website: https://www.medfall.com/ SepOct, NovDec, JanFeb

Upcoming Events: AAEM Directly, Jointly Provided, & Recommended AAEM is featuring the following upcoming conferences and activities for your consideration. For a complete listing of upcoming conferences and other meetings, please visit: aaem.org/education/events

AAEM Events 2024 Oral Board Review Courses TBA Oral Board Review Courses aaem.org/education/events/oral-boards February 10, 2024 Physicians and Patients Advocacy Summit 2024 (Rancho Mirage, CA) aaem.org/event/calaaem-advocacy-summit-2024/ March 6, 2024 DVAAEM Annual Residents’ Day aaem.org/get-involved/chapter-divisions/dvaaem/ April 27-May 1, 2024 30th Annual Scientific Assembly (Austin, TX) aaem.org/aaem24

Re-Occurring Monthly Spanish Education Series* Jointly provided by the AAEM International Committee aaem.org/get-involved/committees/committee-groups/international/ spanish-education-series (CME not provided) February 26-March 1, 2024 44th Annual UC Davis Emergency Medicine Winter Conference June 25-29, 2024 UC Davis Emergency Medicine Summer Conference: InformED October 21-25, 2024 19th Annual Emergency Medicine Update: Hot Topics 2024

Recommended

May 31-June 1, 2024 12th Annual FLAAEM Scientific Assembly (Miami, FL) aaem.org/get-involved/chapter-divisions/flaaem/

Advances in Cancer Immunotherapy™ sitcancer.org/education/aci

Jointly Provided

Online CME Recognizing Life-Threatening Emergencies in People with VEDS thesullivangroup.com/TSG_UG/VEDSAAEM/

Re-Occurring Monthly Unmute Your Probe: Virtual Ultrasound Webinar Series Jointly provided by EUS-AAEM aaem.org/get-involved/sections/eus/resources/unmute-your-probe/

COMMON SENSE NOVEMBER/DECEMBER 2023

COMMONSENSE

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