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Message from the Chair
Ashley E. Booth, MD
There were so many great articles for this edition of the YPS newsletter I thought I would keep this “Message from the Chair” short and sweet. This edition of the newsletter has articles ranging from retirement planning to partner selection to starting a new career and expecting the unexpected.
As always we continue the “Section Connection” series with an article from the International Emergency Medicine Section and the Lifelong Learning Self-Assessment (LLSA) review in this edition of the newsletter.
So read on…I hope you enjoy this edition of the newsletter.
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Message from the Chair-Elect
Abhi Mehrotra, MD, FACEP
First of all, thank you to those of you that were able to join us at ACEP’s Leadership and Advocacy meeting in Washington, DC, this spring. We had a brief business meeting followed by a discussion regarding membership - specifically what it means to have the letters “FACEP” after your name. I’d like to expand on that discussion here.
FACEP – Fellow of the American College of Emergency Physicians, means more than that you are an ER doc or that you are a member of ACEP. Fellow status signifies your commitment to the specialty of emergency medicine. It demonstrates that you are not only a practitioner of emergency medicine, but that you are active in your profession.
How do I apply? After three years of consecutive active membership in ACEP, you will be mailed an application. At first glance, it appears to be an unwieldy, essay-format application, but don’t worry! It’s actually quite simple to complete. You will need to demonstrate qualifications in three of the ten criteria:
- Active involvement in a voluntary health organization or organized medical society
- Active involvement in hospital affairs (committees)
- Active involvement in teaching emergency medicine (EM)
- Active involvement in EM administration
- Active involvement in an EMS system
- Active involvement in ACEP chapter activities
- Research in EM
- Member of a national ACEP committee
- Involvement in the ABEM testing process
- Reviewer for a journal or author of a peer-reviewed published article
The final qualification is that you are board certified by the American Board of Emergency Medicine (ABEM) or by the American Osteopathic Board of Emergency Medicine (AOBEM) to practice as an emergency physician.
Show that you are dedicated to the profession of emergency medicine – apply for fellowship when you are eligible!
Section Connection
International Emergency Medicine – What is it and why Should I Get Involved?
Dustin Smith MD, FACEP
The term “international emergency medicine” prompts a variety of images in the mind of the typical emergency physician. Many start with the picture of a US physician working in a clinic or refugee camp in an exotic location. Others envision collaborating with physicians in other countries, teaching about emergency medicine (EM) systems, methods, and skills to an interested audience. Still others see themselves hosting professionals in their own emergency department (ED), exchanging ideas and learning new methods. International EM is all of this and more.
International EM has had a significant growth as a subspecialty in the last decade. While many specific reasons can be listed for this expansion, the simplest explanation is there is a need for emergency medicine specialists in countries throughout the globe. With the consistent need for humanitarian assistance throughout the world, we as a specialty are uniquely prepared to organize and implement programs that can directly impact people in need.
With our broad knowledge base, capability of making critical decisions with incomplete data, and ability to adapt to stressful work environments, we offer expertise not commonly found in other specialties.
Arguably an even greater impact can be made when the EM skill set is taught to physicians in other countries interested in improving their medical system. US physicians who work in the realm of international EM have the opportunity to teach everything from basic advanced cardiac life support (ACLS) to the best methods of developing an EM curriculum.
While the experience of traveling to other countries to see first hand how their medical system works is important for us, the ability for other physicians to come to the US to observe our medical system is invaluable. The exchange of ideas is a two-way street. By interacting with our colleagues throughout the world we are afforded the opportunity to improve our own systems in the US. Learning what types of healthcare payment structures, malpractice coverage, and disaster response systems work in different environments gives us an advantage in the development of our own systems. We are able to adapt the systems that work and avoid making mistakes others have already made.
So now that you have an understanding of what international EM entails the question becomes – should I get involved? The answer of course depends on what are your goals in life. As a young emergency physician there are lots of new opportunities before you. Pathways to partnership require contributing to your group with shift coverage and administrative work. Academic success means providing shift coverage, research, and teaching. These are just the career goals.
After so many years of training many young physicians are eager to accelerate their personal lives. You can finally spend more time with family and friends who have been so patient over the years. However, I challenge you to think back to what you wrote in your personal statement as you applied to residency. After the years of residency training do you still remember what the spark was that brought you to EM in the first place? I believe that if you are like most emergency physicians you wanted to work in an exciting challenging environment with a team of professionals making a clear and positive impact on your patients and your world. You also wanted to be able to have a life outside of medicine. International EM affords you these opportunities.
There are many ways to get involved with international EM. Those wanting a rigorous structured curriculum should consider an international EM fellowship. Fellowships are typically one to two years, many with the option of obtaining a masters in public health (MPH). The Society for Academic Emergency Medicine (SAEM- www.saem.org) has contact information for 11 international EM fellowships.
If you aren’t yet ready to commit to a fellowship, consider participating in a shorter international rotation in EM. Opportunities exist throughout the world, and a good place to start looking is on ACEP’s Web site, www.acep.org. Under the “sections” page you will find “International Emergency Medicine” that includes a heading for “International Rotations in Emergency Medicine.” This, in addition to the “Join an International Medical Response Team” page, gives useful information on short and long term rotations in international locations.
An alternative way to learn more about international EM without a significant commitment is to attend a conference in an international location. Under the ACEP’s International Emergency Medicine Section page you will find a calendar of international conferences. Upcoming conferences include the 11th International Conference on EM sponsored by the International Federation for Emergency Medicine (IFEM) – in Nova Scotia. Past conferences by IFEM have attracted large numbers of emergency physicians from around the world, and the upcoming conference appears to be of the same caliber. The First InterAmerican Congress on Emergency Medicine – in Buenos Aires, and Global EM Networking – in Sweden, are also just a few of the many international EM meetings you will find listed on the site.
If you don’t have time to get away for even a few days but would like to learn more about international EM there are a few recently updated sources you can read. First the ACEP International Section site has a lot of information. The Emergency Medicine Clinics of North America published an edition focused on international EM with chapters written by many different leaders in the field (volume 23 number 1, February 2005, with L. Kristian Arnold MD and Jeffrey Smith MD as editors).
Finally, perhaps one of the best ways to get involved with international EM is to join ACEP’s International EM section. The section brings together individuals from all over the world to achieve common goals. It is a large, dynamic section with a lot to offer young physicians. From those just starting out and exploring the idea of international EM to those who have been practicing internationally for years, there is something for everyone. Hope to see you at the next meeting.
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Partner Selection is Key to Starting a Successful Group
Rebecca Bollinger Parker, MD, FACEP
Many emergency physicians dream about joining or starting a successful partnership. The common topics of group structure, contract negotiations, and billing and collections are covered in ACEP publications or through consultants; however, the topic of partner selection, the people with whom who you go into practice, is frequently not addressed. It is a topic that is best learned through your own experiences or through the experience of others. Here’s some friendly advice on choosing partners and a few pitfalls to avoid.
Before We Begin
Just to clarify for purposes of this article, most emergency physician groups are organized as limited liability companies (LLC) where the owners are referred to as “members.” However, there are also groups that are organized in the traditional general partnership and those that are organized as a professional corporation where the ownership is by “shareholders.” I use the term “partner” in this article to refer to the owners of any one of the aforementioned entities who, by virtue of ownership, are involved in shared decision-making and operational control of the entity. Additionally, this article discusses groups where the investing partners are pledging their personal credit and finances in order to join or start a group.
A Partnership is a Marriage
Many profess that a partnership is a marriage. Realize this saying means exactly what it says. You are manifestly intertwined with these physicians both legally and financially. Personal information is no longer secret, you make critical decisions together. There are financial obligations and legal obligations, and your partners’ clinical practice reflects directly on you and your clinical practice. You risk your house and assets with these physicians to secure the loan to start the group. You hire physicians together, offer partnerships together, and you must discipline the other physicians and yourselves together.
In the business of emergency medicine, sometimes opportunities arise quickly, and you will be pressured to decide quickly whether to join in a partnership or not. Do not agree to a shotgun wedding. Take the time to get to know you partners in detail. And feel free to walk away at any time if your gut says it’s an error.
Credit Checks and Recent Tax Returns on All Potential Partners
For everyone’s peace of mind, insist that each potential partner submit to a mandatory credit check and a review of tax returns before you agree to start the group. Physicians are mere mortals, and you are better off not taking your partner’s word for their good credit. Your partner may be a stand-up person, but credit is a tricky beast. There may be problems even they don’t know about. Think of it as a fiscal colonoscopy: annoying and intrusive, but potentially lifesaving. Do not sign any contracts, operating agreements, or enter into hospital agreements until this portion is completed. You don’t want to be mid-start up, having made promises to multiple entities, and then have to back out at the last minute unable to explain your actions. On the other hand, if you are mid-stream and don’t feel comfortable with the information you find out, or if a potential partner refuses to release the information, walk away. Do not compromise your entire career and finances on a misconceived sense of personal responsibility, or on an argument that it’s none of your business. This is your business, and you better know what you’re getting into.
Personal Reference Checks On All Potential Partners
Working shifts with someone doesn't necessarily mean that you understand what their business practices are. Take the time to call those references provided to you, and then find a personal reference outside of those provided to you by the perspective partner. These outside references can include any former business partners from any previous venture, and I can almost guarantee that they will provide you with useful information. No one is perfect, and at a certain point you will either trust the person or you won’t, but it never hurts to do your homework.
Review Potential Partner’s Malpractice History
Your future partner’s medical practice history directly affects you. This may not be fair, but you know what they say about life. Previous malpractice claims affect your malpractice rates and your ability to secure malpractice coverage. Do your potential partners have a rough malpractice history? Review the case or cases yourself, with your own eyes. Don’t take someone else’s word for it; trust yourself. Don’t hesitate to discuss the case with the potential partner. Physicians get sued, and you and your potential partners need to be completely open and honest about your past histories.
Know How Your Potential Partners Practice
Before agreeing, work with each potential partner to understand and feel comfortable with his or her practice patterns. As partners, you will review and critique each other’s charts. Your practice patterns will reflect on your partners and vice-versa. Don’t wait until you are already locked in to find out that you do not agree with the way each other practice. People have different styles, and many of them are legitimate; however, that doesn’t mean that everyone’s styles will mesh. I suggest a chart review, or even better a handful of shifts together or both to ensure that you get along from a practice pattern perspective.
Establish a Leader
Someone must take responsibility as Captain of the Ship and steer the ship. Find someone you feel comfortable following, and then give him or her the power they need to get the job done. Have a fair removal process just in case, but realize that these physicians are often caught between pleasing the hospital and advocating for the group—a potentially unenviable position. If you have a physician particularly adept at management, don’t rotate this leadership position out of ostensible fairness. Successful Fortune 500 companies don’t rotate chief executive officers (CEOs) out of fairness to the other executives, and neither should you. Develop a strong leader and let them lead. If you insist on rotating the position, make it multi-year terms. When that leader is ready to step down, they should have already developed the next candidate. Please keep in mind no successful business is run by a true democratic vote on every issue. Voting on every single aspect runs your ship aground and business doesn’t get done. The group becomes an indecisive mess of poor decisions that threatens the long-term stability of the contract. Also, the hospital wants to know that one person takes ultimate responsibility, and that they can go to that person to correct any problems or discuss issues.
Put it in Writing
Put everything in writing before you start the group. Of course, you make verbal agreements beforehand, but put these agreements in writing and have a third party, such as a secretary, take minutes as discussions progress. If you don’t take minutes or notes, there is no guarantee that points you agreed upon will appear in the final contract. You must do this BEFORE you work a single day with this new entity. Topics such as future partner additions, exit methods, non-competes, etc. may seem obvious when you speak about them, but until it’s in ink, and everyone signs on the dotted line, nothing is guaranteed.
Don’t sign an LLC agreement in haste. There are a thousand wrong reasons to fall into this scenario. Everything is always urgent in this business, and finishing the contract will prove no exception. Take your time. What you sign will most likely endure, and there’s no guarantee you will ever change it. You will most likely never revisit these issues ever again. After you sign the papers, the ship comes out of dry dock, and the course is set. Major changes from this point on are tough to impossible. Don’t panic, and don’t rush into anything.
Some Parting Words
There are many challenges to starting a successful group, and it helps to have a long-standing relationship with the physicians before you start your adventure. There are also many other factors in deciding whether or not you wish to work with a specific group of people. This article only deals with partner selection. If you’re surrounded with the right people, it can be a wonderful, rewarding practice environment. If you’re surrounded with the wrong people, it can be a daily challenge. I realize that some of what I suggest is a best-case scenario for starting a group, and you may not get the opportunity to do all of it, but never doubt your better instincts. If something smells rotten, it probably is. Do your homework before you jump in to avoid pitfalls.
If you have any stories about starting a group that you wish to share with me, or you have any questions about my experience, please email me c/o youngphy.section@acep.org I will help you the best I can, and if I don’t know the answer, I will try to find you someone who does. Best Wishes.
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Starting Your Career: Expecting the Unexpected
Jennifer Avegno, MD
Starting a new job is always equal part exciting and terrifying. For me, making the leap from residency to full-time emergency medicine (EM) staff magnified those emotions. I remember counting the days until my first “real” day of work, and thinking – if I can just get through the first few shifts without screwing up, I’ll be home free! Little did I know that my biggest hurdle was not starting a new career, but re-starting one just two months into my career.
After graduating from a four-year residency at LSU – New Orleans, I felt prepared to handle a full-time job as staff at Tulane University Hospital and LSU Medical Center of Louisiana at New Orleans – both tertiary-care, academic teaching facilities. That’s not to say I wasn’t scared; I spent the night before my first shift reading up on precipitous delivery techniques, neonatal resuscitations, and rare and strange procedures ... just in case! My first shift was a relief: nothing I couldn’t handle, no one died, no consultants asked for my experience or credentials. Slowly, I got into the groove that comes to everyone, and by mid-August I was no longer getting butterflies in my stomach each time I hit the emergency department (ED) door.
And then ... everyone knows what happened in New Orleans in late August 2005. Both of my hospitals were flooded, abandoned, devastated; my house had four feet of water; half of my family was homeless; my colleagues and friends were scattered; my city was destroyed. I had received exactly one paycheck since beginning work – and the student loan companies’ sympathy has its limits. It wasn’t exactly the way I thought my career would progress.
But with every crisis brings great opportunity to grow. My colleagues and I were able to remain in constant contact and united around the need to ensure our residents’ safety and training opportunities. No hospital available? We partnered with the US military and began seeing urgent care and seriously ill patients in a mobile army surgical hospital (MASH) unit. Never did I imagine that I would begin an academic career in a tent. We drove to Baton Rouge, Lafayette, and other places around the state where our residents temporarily rotated in EDs to ensure there would be a consistent LSU – New Orleans staff presence. We applied for grants to continue research and education. We held weekly conferences and journal clubs, and above all else, took care of patients.
In the true spirit of EM, we did what we had to do – for our patients, for our students and residents, and for our community. Now we have a brand-new state of the art ED and trauma center, and many of us who started our careers in a tent have taken active leadership roles that would have been previously unavailable. Just as all my best-laid plans after graduation washed away with the floodwaters, I was given a completely new and unexpected path to take, and it has proven equally challenging and satisfying.
Fortunately, most young emergency physicians will never have to deal with the aftermath of a hurricane – but the lessons I learned are universal. When I debrief the graduating residents about the past two years, here’s what I tell them I’ve learned from this experience:
Be flexible. Just because you’ve had your life and career mapped out for years doesn’t mean it will stay that way ... rolling with the punches often brings greater success and greater opportunities than ever.
Be involved. Not everyone can work at multiple institutions, but having connections and networks outside of your main employment can prove fortuitous when disaster strikes. Sometimes hospitals close, departments shut down, or groups lose contracts very quickly – and it’s best to always keep your options open and available.
Be prepared. Plan for what you will do when disaster strikes. It may not be a hurricane but a serious illness of you or a loved one, an abrupt change in your job satisfaction, a mid-life crisis, an urgent need to move to another part of the country, or anything in between. You can’t predict the future, but you can prepare for anything. This includes financial stability – I feel very fortunate that I had not blown my one paycheck on a big “happy graduation” present to myself!
Every graduating resident deserves sincere congratulations for many hard years of work and a job well done. Some will move easily into their chosen career path and continue on it undisturbed. Most will, I suspect, hit bumps in the road – big and small – that may completely veer them off course. There’s always an alternate path, and as the poet wisely observed: “I took the road less traveled by, and that has made all the difference.”
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Asset Allocation Can Make a Big Difference in Your Investment Return
Randy S. Kurland, CPA, MBA, PFS
Abstract: Putting your investments into the right mix of assets can be the most important factor in how well they perform.
Some investors think the key to success lies in picking the "right" investment. They follow the trends and put everything into the hottest category. And then they’re surprised when that category cools off.
In fact, picking the right investment or the right time to buy or sell is far less important than you may think. Studies have found that approximately 90% of the variability of investment return across time is explained by asset allocation—that is, the distribution of dollars among asset classes, such as stocks, bonds, and cash equivalents. 1
Asset allocation—sometimes referred to as diversification—simply means determining what percentage of your portfolio will be in stocks, bonds and money markets, and within each of those groups, which particular types of stocks and bonds. For example, a portfolio may be 50% invested in stocks, and within that group, some may be in stocks of large companies, some may be stocks of small companies, and some may be in stocks of non-U.S. based companies.
The reason for asset allocation is that different investments can behave differently under the same conditions; for example, small company stocks may rise in value while large company stocks decline. Stocks and bonds often perform in different ways, so investing in a mix of stock and bond funds can improve the performance of your overall portfolio, cushioning your savings against price swings in one asset class.
In terms of return, a diversified portfolio containing both stocks and bonds will generally perform better than either an all-stock or all-bond portfolio over a full market cycle. During the bull market of 1995-1999, a diversified portfolio achieved higher returns than an all-bond portfolio. During the bear market of 1999-2002, the diversified portfolio outperformed the all-stock portfolio. Of course, diversification does not eliminate risk and past performance is no guarantee of future results. 2
Your Particular Mix is a Personal Decision
A diversified portfolio typically includes at least three categories of investments: stocks, bonds and money market investments. How much should you allocate to each category? Your financial professional can help guide you, based on:
- Your investment goals. If you're investing with the hope of generating big returns and you have the tolerance for the increased risk involved, you might consider placing greater emphasis on higher-risk growth-oriented investments, such as stocks.
- Your time horizon. If you have many years until you'll need the money, you can often afford the risks associated with growth-oriented investments, because you have time to help recoup any potential losses. Money that you'll need soon should generally be in lower risk investments, such as bonds or money market funds.
- Your tolerance for risk. Can you handle a drop in the value of your investments without pulling out in a panic? Don't rely on volatile investments if you can't stay the course.
- Your financial situation. Do you have other resources, or are you low on funds and near the end of your working career? This, too, will help you determine how much risk you can afford to take.
Asset allocation can help you manage risk and potentially increase your returns. However, it does not guarantee a profit or protect against loss. For more information, contact your financial professional.
References:
- Ibbotson Associates, “Portfolio Diversification,” How important is asset allocation? Slide 3, 2006.
- Ibbotson, “Portfolio Diversification,” Diversification in bull and bear markets, Slide 10, 2006
AXA Advisors, LLC does not provide legal or tax advice. Please consult your tax or legal advisor regarding your individual situation. GE-35910 (05/06) (Exp.05/08)
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Keys to Retirement Success
Randy S. Kurland, CPA, MBA, PFS
Abstract: Follow some basic guidelines to improve your chances of having a comfortable retirement.
Remember the tortoise and the hare? Slow but steady works in investing too. If you want to retire with a comfortable nest egg, here are some simple rules that can get you there.
1. Pay Yourself First
Deciding to save regularly is a crucial first step. Sticking to a savings plan is certainly another. You're probably already participating in your company's retirement savings plan. But are you contributing to the fullest extent allowable? Remember that you could live in retirement for 25 years or more without any salary income. It could take a substantial amount of savings to carry you through for that long. If you have contributed the maximum to your qualified retirement plan, talk to your financial professional about other types of savings/investment plans.
2. Start Early
Compounded growth can work wonders for your savings—provided you give it time. Let's say, for example, that you begin saving $100 a month at age 35. Compounded monthly at a hypothetical 8% per year, your savings can grow to $149,036 by age 65. Pretty good, right? You can do better. Begin saving ten years earlier and the same $100 a month can grow to $349, 101 – more than twice as much! 1
3. Invest to Outpace Inflation
A common mistake is to play it too safe. Inflation could steadily erode your earnings. Historically, inflation has averaged between 3 and 5 percent over the last 90 years.2 Your investments need to earn more than the inflation rate or your return will actually be going backward. At 4 percent, inflation could eat up half of your earnings over 18 years.
4. Diversify
3Knowledgeable investors allocate their money among different kinds of asset classes: money market funds, bonds and stocks. Within these asset classes, you may want to diversify further, for example, by investing in some stocks that have high growth potential and others that pay dividends. Your financial professional can help you determine the suitable amount to put into various asset classes, depending on your age, your risk tolerance, your time horizon and your goals. By sticking to an asset allocation plan,** you limit your risk of exposure to just one asset class and can benefit from market shifts.
5. Invest According to Your Time Horizon
As you get closer to retirement, you have less time to recover from dips in the market. You may want to shift some assets into investments that tend to be more stable. But don’t forget that you may need to live off your retirement funds for many years. Investing for some growth potential in your portfolio is usually a good idea.
6. Avoid Dipping Into Your Tax-Deferred Savings
You'll net less than you think because the withdrawn funds become taxable income. And in many instances you could face an additional 10% federal tax penalty if you are not yet age 59 1/2. Plus, any money you spend now is money you won't have later. And you could miss out on years of compounded earnings. If you need the money temporarily, it may be a good decision to take a plan loan (if permitted) and repay it promptly. 4
7. Avoid Trying to Time the Market
When the market is hot, many people are tempted to play the stock market with their retirement savings. If you’re one of them, consider setting aside a small amount that you can afford to lose and use this “allowance” to play the market. For the bulk of your retirement investments, stick to your asset allocation plan.5 Don’t shift funds from one account to another simply because one showed higher returns. Performance in the immediate past is no indicator of the long-term future. The market frequently undergoes sudden and dramatic shifts.
8. Think Long Term
Don't be alarmed by day-to-day swings in the stock market. For most of us, steady investing, compounded earnings and maintaining a planned asset allocation 6 are the keys to successful retirement planning. Decide on an appropriate long-term mix of investments and try to stay the course. Slow but steady is the best way to get where you’re going.
For more information about establishing a financial plan, contact your financial professional.
References:
- This example is a hypothetical intended for illustrative purposes only and is not indicative of the actual performance of any particular product. These figures are not intended to represent the performance of any specific investment, insurance contract, or other financial product. This example does not take into account the impact of any fees or taxes.
- US Dept of Labor monthly Consumer Price Index, bls.gov/cpi
- Diversification does not eliminate the risk of experiencing investment losses.
- Withdrawals are reported as income and are subject to ordinary income tax treatment (as opposed to capital gain or dividend income) and if made prior to age 59 ½ may be subject to an additional 10% federal income tax penalty. In addition, company imposed surrender charges may apply to certain withdrawals.
- Asset allocation is a method of diversification which positions assets among major investment categories. This tool may be used in an effort to manage risk and enhance returns. However, it does not guarantee a profit or protect against loss.
AXA Advisors, LLC does not provide legal or tax advice. Please consult your tax or legal advisor regarding your individual situation. GE-35969 (07/06) (Exp.07/08)
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HHS Encourages Physician Enrollment in New State Programs for Disaster Preparedness Response
Rear Admiral M. Craig Vanderwagen, Assistant Secretary for Public Health Emergency Preparedness at Health and Human Services (HHS) last week said that physicians should register as volunteers with state credential programs to help at the site of natural disasters or other emergencies. Currently, no national credential program exists for physicians, which presented a problem for physician volunteers after Hurricane Katrina. Many states have begun to establish credential programs as part of the Emergency System for Advance Registration of Volunteer Health Professionals administered by the Health Resources and Services Administration.
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ACEP/EMRA Mini-Fellowship in Health Policy
Brief Project Background
For several years, the ACEP D.C. office has hosted residents with an interest in healthcare policy and leadership. This experience has provided an opportunity for young physicians to refine their advocacy skills with hands-on experience on Capitol Hill. The development of a formal health policy mini-fellowship program is an extension of these efforts. EMRA and YPS members have requested the construction of an intensive, short-term policy curriculum that will provide meaningful advocacy exposure. A concise, well structured program will augment current leadership efforts by professional societies like EMRA and ACEP to develop a cadre of energetic, educated physicians capable of pursuing an Emergency Medicine advocacy agenda on state and national levels. The “ACEP/EMRA Mini-Fellowship in Health Policy in Washington DC” has received formal approval from both EMRA and the ACEP Boards, and is currently soliciting applications for the 2008 calendar year.
Program Structure
The approved mini-fellowship provides a four week experience centered out of ACEP’s Washington, D.C. office. Two fellows will be selected from a pool of applicants for this opportunity. Each fellow will receive an award of $2,500 to help defray the costs of living in the D.C. metro area. Fellows will focus their efforts around custom learning objectives consistent with their specific pre-defined areas of interest (lobbying, policy, legislation, regulation, non-governmental organizations, etc). Fellows will be expected to present their work at a national conference and/or in other relevant emergency medicine publication venues. They will receive a midpoint evaluation and an overall evaluation at the conclusion of their experience by program faculty.
The fellowship will be guided by Mr. Gordon Wheeler, ACEP’s Associate Executive Director at the Washington office. The fellows will also be expected to work closely with ACEP staff members at the Washington office. In addition, Dr. Janice Blanchard, MD, MPH, MPhil will serve as a faculty mentor for the program. Dr. Blanchard is an assistant professor at the George Washington University’s Department of Emergency Medicine and an adjunct faculty member of the GWU Department of Public Health. Fellows may choose to incorporate participation in GWU’s “Resident Rotation in Health Care Policy”. This program is a resident rotation that provides resident physicians with a comprehensive understanding of U.S. health policy. The curriculum delves into issues relating to health care access, financing, regulation, health care quality, disparities, public health protection, and critical fields of health care law. The three week GWU RRHP is offered twice annually, with upcoming dates from October 1-19, 2007 and March 10-28, 2008. Fellows who choose to participate in this intensive course must attend at least 14 of the 19 classes or may choose to participate in GW Grand Rounds discussions on health policy. Our goal is that fellows will utilize the resources centered at GWU and the ACEP DC office to meet with important policy makers, understand key federal regulatory and legislative bodies, and develop skills to engage policy professionals and meaningfully contribute to the national advocacy landscape.
Eligibility & Application
The mini-fellowship program will select individuals with a history of leadership and with a clear commitment to health care advocacy. Applications are actively being solicited and will be collected through July 15, 2007. The fellowship is available to EMRA members (emergency medicine residents and fellows) and ACEP Young Physician Section members. Applicants must be less than 5 years out from their residency training. Candidates must also submit a formal letter of interest, curriculum vitae, two letters of recommendation, and a letter of support from a faculty sponsor at their home institution.
Selection Committee
The selection committee will review all applications and select candidates in early August 2007. The committee will be comprised of staff members from the ACEP D.C. Office, the ACEP Young Physicians Section, the ACEP Board of Directors, a GWU Faculty member, and EMRA.
Suggested Reading Curriculum
The ACEP Federal Government Affairs Committee has suggested the following materials as an integral part of the Mini-fellowship curriculum:
- Thomas Bodenheimer & Kevin Grumbach. Understanding Health Policy: A Clinical Approach, 4th edition, McGraw-Hill Medical, 2004.
- Eugene Bardach. A Practical Guide for Policy Analysis, Seven Bridges Press, 2000.
- Jim Mitchiner, MD – EMTALA Primer
Proposed Timeline
| May - July 2007 |
Call for applications |
| July 15, 2007 |
Application deadline |
| September, 2007 |
Announcement of Fellows/Distribution of curriculum & materials |
| October 2007 |
Submission of interest areas and project proposals |
| May 2008 or May 2009 |
Publication of Fellow Projects/Report to EMRA and ACEP Boards |
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Regulatory Update
CMS Prepares to Release (Your) NPI Information to the Public
CMS published a notice in the Federal Register May 30, 2007 describing plans to allow the public to query the NPI database. On a call hosted by CMS June 14th, staff announced that providers should query the database to see if their information is correct and delete "optional" information they don't want released. While CMS has asserted they have the authority to release most data information supplied by a physician on their NPI application, a physician's social security number, date of birth, and IRS Taxpayer Identification Numbers are not disc losable to the public. You can review and delete your optional information by going to https://NPPES.cms.hhs.gov or by calling the NPI enumerator, NPPES, at 800-465-3203, for a change of information form.
NOTE: If you must make changes to information pertaining to SSN, date of birth and state of birth, these changes must be submitted on paper. CMS wants everyone to have this completed by June 28.
From ACEP's 911 Network Weekly Update
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LLSA Review
Following is a continuation of article reviews for the 2007 Lifelong Learning Self Assessment (LLSA) exam. Enjoy!
High Prevalence of Methicillin-Resistant Staphylococcus aureus in Emergency Department Skin and Soft Tissue Infections
Ann EM. March 2005; 45(3):311-320
The main objectives of this article are to determine the prevalence of MRSA in ED patients with skin and soft tissue infections, to identify demographics and clinical variables associated with MRSA, and finally to characterize MRSA by antimicrobial susceptibility and genotype.
Early research in the 1980s identified MRSA in the community to be due to hospital-based transmission, but in the 1990s reports started to involve patients with community acquired infections without recent health care facility contact.
This article describes a prospective case series using a convenience sample of 137 patients of an urban county teaching hospital emergency department (ED) in northern California. These patients presented with skin and soft tissue infections ranging from cellulitis to abscess or ulcer. Enrolled participants were asked to complete a health history and lifestyle questionnaire including a detailed assessment of antibiotic use, drug use habits, and housing history.
A multivariate logistic regression was conducted to determine predictor variables independently associated with MRSA. Cultures taken from the subject’s nares and site of the infection were cultured and gram stained. In addition, minimum inhibitory concentrations for MRSA specimens were determined, and MRSA isolates underwent genotyping using electrophoresis.
The study authors found that for their population, the demographics revealed 18% homeless, 28% illicit drug injectors, and 63% had a deep or superficial abscess. Seventy six percent (76%) were community acquired cases, and the strongest predictor variable independently associated with MRSA infection was infection type being furuncle (OR=28.6). Additionally, MRSA was present in 51% of the infection site cultures. Antimicrobial susceptibility studies demonstrated 100% susceptible to trimethoprim / sulfamethoxazole, 94% susceptible to clindamycin, and 86% susceptible to tetracycline. Ninety-nine percent of MRSA isolates possessed the SCCmec IV allele (typical of community associated MRSA), 94.1% possessed the Panton-Valentine leukocidin genes, and 87.1% belonged to a single clonal group.
Conclusions drawn from this study included that MRSA is a major pathogen in skin and soft tissue infections in this urban population, but further studies are needed from other practice settings. Also, when prescribing empiric antibiotics for skin and soft tissue infections, MRSA should be considered.
Are Blood Cultures Necessary in Adults with Cellulitis?
Ann EM. May 2005;45(5):548-549
The authors conducted a review of five original articles to help answer this question. The authors’ search strategy was to use Ovid MEDLINE and search key words “blood cultures” and “cellulitis,” which yielded 122 research articles. They examined bibliographies of these articles as well to identify other related articles. The two authors examined all articles and included only original published research articles with a primary focus specifically addressing the utility of blood cultures in adult cellulitis.
Three of the studies were retrospective reviews of admitted adult patients with cellulitis, while two were prospective. All five studies concluded that blood cultures taken from adults with cellulitis do not significantly change chosen antibiotic regimens in relatively healthy adults. However, none of the studies adequately addresses more complicated cases of cellulitis including immunocompromised patients, patients with exposure to unusual organisms or patients with severe underlying diseases. The authors of this review article state that it would be within standard of care to not obtain blood cultures in otherwise healthy adults who present with apparently uncomplicated cellulitis.
Clinical Value of the Total White Blood Cell Count and Temperature in the Evaluation of Patients with Suspected Appendicitis
Acad EM. Oct. 2004; 11(10):1021-1027
The aim of this study was to assess the clinical value of total WBC count and temperature in patients presenting to an emergency department (ED) with signs and symptoms suggestive of acute appendicitis.
The study was a prospective study of 308 (after loss to follow-up, total was 293) consecutive patients presenting to an urban academic ED with signs and symptoms of acute appendicitis as the primary diagnostic consideration. Pregnant patients were excluded. Data recorded included age, gender, total WBC count from the complete blood count (CBC), patient temperature in the
ED, result of computed tomography (CT) scan, presence of appendicitis or perforated appendix from operative or pathologic report, and final diagnosis.
Results showed total WBC count >10,000 cells/mm3 had a sensitivity of 76% (95% confidence interval = 65% to 84%) and a specificity of 52% (95% CI = 45% to 60%). The PPV was 42% (95% CI 35% to 51%) and the NPV was 82% (95% CI = 74% to 89%).
Additionally, temperature >99.0 degrees F had a sensitivity of 47% (95% CI 36% to 57%) and a specificity of 64% (95% CI 57% to 71%) while the PPV was 37% (95% CI 29% to 46%) and the NPV was 72% (95% CI 65% to 79%).
Even though both of these are a routine part of the clinical work up for appendicitis, conclusions drawn from these findings found very little clinical utility to elevated total WBC count or elevated temperature, and therefore clinicians should not rely on these as an indicator of acute appendicitis.
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YPS Yearbook
Members from the past ……..where are they now
YPS Member: Gary Katz, MD, MBA, FACEP
Medical School: Medical College of Ohio
Residency: Summa Health System, Akron Ohio
YPS Membership: Secretary/Treasurer 2002 - 2004
Current Job Title: Assistant Professor
Department of Emergency Medicine
The Ohio State University
ACEP positions: AMA Section Council for Emergency Medicine
Other positions: AMA’s Young Physician Section- Chair
Advice to young physicians: I believe that involvement in organized medicine is a professional responsibility of each and every physician. While we are at work, we are impacting people one patient/family at a time, but through organized medicine we can make positive change for a state, region, or even the nation.
The demands placed upon early career physicians are great (educational debt, an unfavorable schedule, building a home and family) and should take precedence over organized medicine activism. However, the participation in both ACEP and the American Medical Association (AMA) with even a basic membership can do so much to advance emergency medicine that it truly can make both your job and other stressors in your life easier.
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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.
