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Wellness Section Newsletter - January 2007, Vol 11, #1

Wellness Section

circle_arrow A Note From The Chair: What is Wellness?
circle_arrow Wellness and Patient Satisfaction Surveys
circle_arrow Core Readings in Wellness for Emergency Physicians
circle_arrow The Challenge
circle_arrow Book Review - Lincoln's Melancholy
circle_arrow And So It Goes
circle_arrow The Wellness Section Web Page
circle_arrow The Doctor
circle_arrow Reflections on Variation
circle_arrow An Antidote to Stress
circle_arrow Wellness Section Meeting Minutes - 2006 Scientific Assembly


Newsletter Index


Wellness Section

 

A Note From The Chair: What is Wellness?

Mitchell B. Cordover, MD
Chair, Well-being Committee

What do we mean by wellness? For years ACEP has provided a home for the Wellness Section. Recently, the college has reinvested in a standing committee on Wellness. ACEP is a serious-minded and influential national organization. It is arguably the most important voice for emergency physicians in our nation and an example for nations across the globe as they develop our specialty. What would so prestigious a group need from a committee on personal wellness? Why include it with activities like regulation, legislative lobbying, and physician education?

Wellness is the state of good physical and mental health, especially when maintained by proper diet, exercise, and habits. It implies a sense of vigor and personal satisfaction, rather than the simple absence of disease. It clearly includes a personal, spiritual side, suggesting a sense of meaning in one's life and a satisfaction with ones overall career. Ironically, it is this more psychological and spiritual side that most people think of when wellness comes to mind. Surely, overcoming the stress of the job, having a productive attitude toward troublesome patients, and keeping a positive state of mind are significant challenges for us. But for emergency physicians, there is a physical side of wellness as well, as we will discuss.

Many of the greatest obstacles to well-being cannot be approached personally, but require political action at the local and national level. Overcoming unfair and threatening regulations, unhealthful local scheduling practices, physician or nurse understaffing, predatory contracting, or poor security practices are matters that require policy support from the College and concerted action at the practice and the regional level. Wellness is not only a matter of personal transformation and recommitment to ones goals. Good diet, sleep, and exercise are not enough. Establishing a wellness-promoting environment means identifying structural risks in your environment and then educating stake holders, lobbying decision makers and budget makers, and winning changes that make a difference.

This is an issue of more than personal importance. It is easy to see the manpower implications of wellness. For physicians to choose and stay in this specialty there must be some promise of a healthful and satisfying life. Every investigation shows that lifestyle is a more important determinant of residency choice than ever before. Likewise, decisions about early retirement and changes in practice are strongly influenced by wellness issues.

Wellness also has important implications for the strength of the specialty and the quality of care. The growing public taste for convenience in health care, the loss of access among the uninsured or underinsured and the desire among private practitioners to themselves enjoy a reasonable lifestyle have contributed to an explosion in emergency department (ED) volumes in recent years. However, public demand does not guarantee that the quality of emergency services will continue. Without the promise of a healthful and satisfying professional life, the best and brightest will simply go into other professions or other specialties and the quality of care will suffer.

It was not so long ago that EDs were run by interns, rotating faculty, and a hodgepodge of general practitioners, on-call retirees and specialists from various other fields. The advantages we have won in the areas of reimbursement, clinical privileges and prestige among our colleges reflects our improved ability to provide consistently excellent care. That requires a stable and growing body of committed specialists. Wellness is the sine qua non of a growing and vibrant field.

It is likewise for the College itself. However well ACEP may do in improving national access to care and fending off reimbursement threats, it cannot thrive unless doctors can feel well in this field. Under-slept, depressed, under committed people in deteriorating medical marriages, who feel abused by unfair business or licensing rules, and who feel threatened by violence or disease while working jobs that promise little grown in their skills may not want to pay dues for the privilege. A member who has once been defended in a struggle over substance abuse, supported in litigation stress, or provided with helpful guidance about policy is the best guarantee that ACEP has of continued strength.

This year, the Wellness committee is reexamining the issues we will address in this and subsequent years. Here is an incomplete list of issues we are considering.

  • Safety and security: avoiding the risk of intimidation, physical attack, or abuse at work, insuring ready availability of help with violent or irrational patients
  • Fitness and health promotion: education about the importance of and encouragement of health promotion including the availability of work-based fitness opportunities, dietary options, health risk abatement, regular medical testing and attention to health risks
  • Contagion and immunization: proving early warning, preventive equipment, differential access to appropriate vaccines, and adequate preventive education
  • Circadian stress and scheduling: education, training, technical assistance and policy support for a 24/7 operation
  • Torts and litigation stress: risk management education, career protection materials and personal support/counseling during periods of suit-related personal stress, support for college activities that improve the malpractice climate
  • Medical marriage and relations: education and literature review in special stresses of professional marriages, encouragement of support group development
  • Relations to patients and staff: policy support, education and promotion of productive professional and therapeutic relations, including with trouble or difficult staff and patients
  • Aging: investigation, policy support, resources and guidance for the preretirement period and the transition to reduced practice
  • Growth, challenge and profession satisfaction: promotion and support for the wellness significance of widening the skill sets, professional respect and challenge
  • Substance abuse, impairment and recovery: promote prevention, early detection, availability of recovery opportunities and fair treatment of physicians in remission
  • Behavior and psychiatric disorder: promote prevention, early detection, availability of recovery opportunities and fair treatment of physicians whose practice is not impaired or who are under adequate treatment, suicide prevention

Wellness is an essential personal and professional activity, and the college is rightly focused on better defining and implementing policies and programs in the area.

 

 


 

 

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Wellness and Patient Satisfaction Surveys

Mitchell B. Cordover, MD

My hospital has recently changed its policy to make patient satisfaction scores a significant factor in their annual pay review for the employed doctors. It has put teeth into what has previously been a campaign of nagging and cajoling. The change was enough to prompt this report of the complaints that I've been hearing recently on this subject. Patient satisfaction is not the same as patient satisfaction surveys! From a wellness point of view, they may well have opposite effects.

The relationship between patient satisfaction and an emergency physician's job satisfaction has been widely discussed. The theory is that health care providers, like everyone, feel happy and rewarded when they are well-liked and appreciated, and that patients are an especially important source of feedback. Doctors are heavily invested in their professional identity so they are particularly sensitive to the any reflection on it. A positive feedback loop can be established, with the patients being cordial and responsive to the doctor, who in turn likes seeing patients better and is nicer to them. It's not a panacea, but it's said to be a protection against the evil twin of this feedback loop, so common in states of burnout. I admit that this widely held belief about being nice is very hard to prove scientifically, but we have all experienced it so let's just say that patient satisfaction is a generally good thing and is good for us as emergency physicians.

The recent popularity of hospital-sponsored patient satisfaction surveys is an entirely different matter. These are generally done as phone interviews or mail-out written surveys, performed days to weeks after a visit. They commonly limit themselves to people who were discharged. The most widely used commercial version asks 4 questions that directly relate to the physician's care. The other of the questions are about nursing, waiting times, parking and so on. It then asks about the patient's global satisfaction. Would you return to this facility, would you recommend it to your friends? It is these questions that are the most salient to hospital administrators whose opinions will affect our fate.

The scientific validity of this kind of research is not at issue here, but is clearly weak. Not that the statisticians at these firms are naïve. They remind clients that used in aggregate, over a long period, in conjunction with other information and in comparison to broad benchmarks, these are useful data. However, hospitals are using the numbers on a quarterly or even monthly basis, divided up by practitioner to make quality judgments about our care and our character. They may use as few as five or ten results, provided by the patient with whom we spend the least time and whose opinion is, in the interim, affected by subsequent health results, others' opinions and factors unrelated to their ED experience. Overall validity notwithstanding, the number of results is too small to control for factors known to be important, like age, economic status, and prior health. The care we deliver is finely matched to individuals' needs, so the patient's own presenting complaint certainly will affect their experience, as will their expectations and previous encounters. And that does not even take into account their ideas about which medicines they think they should get. In any event, those with the strongest feelings are more likely to respond.

Significantly, what the facilities seem to care about the most, however, are the questions about patient loyalty. The hospital is using patient satisfaction the way other businesses do, to provide them with a competitive advantage, expand their catchment area, and to harvest and merchandise up repeat business (if you liked our ED, wait 'til you try our open heart surgery!). These are worthy goals for those who are responsible for making the hospital a profitable enterprise, but I would contend that making our patient relationships part of this commercial scheme is bad for medicine and bad for physician wellness.

Moreover, placing any more than a small portion of the burden of hospital-brand loyalty on the patient's recollections about physician courtesy is unfair and unproductive.

In prior years, a patient came to a physician as part of a culture of expertise. The "patient" role requires a balance between self-determination and respect for specialized knowledge, engagement and surrender of control, and a sense of the importance of the patient's own time verses the recognition that they are using a limited and important social resource. The doctor-patient interaction might well include unpleasant news, warnings about personal habits, and advice that is potentially stern. "Patients" are liable to be disappointed, especially if they have expectations that are unrealistic or demands that are uninformed.

The hospital's recruitment of this interaction into their business plan makes the patients into customers! Being medically responsible and treating the "customer" in a way that will make them want to "shop" there again is often impossible, and places us in a far less satisfying role.

Physician wellness depends in part on our ability to have honest and caring relations with those who need our help. How likely am I to honestly intervene into a smoking, drug or drinking habit when I depend on the "customers" good opinion for my evaluation? Will it affect my use of narcotic pain medications? Can I educate patients on the appropriate use of my facility? Not if I am a salesperson for the hospital's wares. "Of course you can have a CT scan. The customer is always right." I'm not suggesting that we be rude, cavalier, cruel, or uncaring. Only that the professional identity we so depend on for our wellness is eroded by over commercializing a service that was intended for emergencies.

Hospitals are economic entities, but they are not like shops or other branded services. If we are to maintain a sense of work satisfaction, we will need to resist attempts to include our expert professional services into the marketing schemes that are ill-designed to measure what we should be doing.

 

 


 

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Core Readings in Wellness for Emergency Physicians

The membership of the American College of Emergency Physicians is aging! Over twenty-five percent of currently registered physicians are over the age of fifty. Issues related to retirement are facing many of us. The following article is a good introduction to some basic considerations.

Anast GT. Editorial: Managing a successful retirement. Surgery. 1997;121:474-476.

The author suggests the secret to success and happiness in retirement is to see it as a new career and prepare just as assiduously as you did for your career in medicine. The emphasis should be on psychological preparation. Physicians have a tendency is to identify totally with their profession from a personal standpoint. Retirement can entail a loss of identity in exchange for a freedom that is unfamiliar, and can seem meaningless in the absence of useful work. This effect can be devastating. The major problems associated with retirement are emotional and mental and typically involve a series of adjustments:

  • Self-Identity: "If I am no longer a doctor, then what am I?" You will view yourself differently, and be seen differently by others. Finding a new identity in retirement can be difficult unless planned for in advance.
  • The New Peer Group: You will no longer have contact with your colleagues and professional contacts on a daily basis. Plan carefully for the type of environment you will choose in retirement, seeking above all, the company of like minds.
  • Remain Active Socially: Maintaining or gaining a circle of friends is crucial. Relocation should be approached with special care, the most serious concern being loss of psychological support.
  • Be of Service to Others: Volunteer medical work, including work overseas, is readily available, and a potential source of immense gratification for the retiring practitioner.
  • Cultivate Interests That Engage Your Mental And Physical Resources: Such activities are especially important in maintaining intellectual acuity and physical fitness.
  • Spousal Relationships Will Change: Both you and your spouse will face adjustments as you begin to spend more time with each other.
  • The bottom line: the transition from practice to retirement is rarely seamless. Physicians are well-advised to carefully consider and prepare for the adjustments to be made.

 

 


 

 

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The Challenge

Jay Kaplan, MD, FACEP

I am challenged by my life
life or death
which will it be?

what seemed steady and certain
abruptly disappears
and I am left grasping for handholds
attempts at balance almost futile

in this darkness
my eyes open
I try to see more clearly
why
when
how
risking movement
my heart pounds

a voice whispers
the duel has begun
take your steps

my voice answers
I want to walk with vigor
even as the ground shifts
and the night remains
and the wind howls

my adversary hides
feeling certain of victory
I continue step by step
one foot in front of the other

I will not hide

Faith fills me with courage
Humility readies me for any outcome

I will not lose as long as I accept the challenge

 


 

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Book Review - Lincoln's Melancholy

Louise B. Andrew, MD, JD, FACEP
Richard M. Goldberg, MD, FACEP

Lincoln's Melancholy1, a recently-published book by Joshua Wolf Shenk, has received wide-spread acclaim as a scholarly and exhaustively-documented work. Though the emotional aspects of his life have been minimized by prominent Lincoln historians of the 20th Century, contemporary reviews of primary source materials now provide ample evidence that Lincoln suffered from an enduring and at times near-fatal depression.

Lincoln suffered at least two major depressive episodes, as defined by the Diagnostic and Statistical Manual of Mental Disorders.2 The first occurred in 1835, a time of intense pre-occupation both with his law studies, and the illness and subsequent death of Ann Rutledge, a woman for whom he had developed a strong affection. In the weeks following her death, Lincoln became withdrawn, spoke openly of suicide, and confided to a friend that he was so overcome with mental depression that he did not dare carry a knife. Clearly unable to care for himself, neighbors took Lincoln in until he was able to live safely again on his own.

The second episode occurred in 1841. It is likely that several events, occurring in close order, precipitated the breakdown. Lincoln had broken off his engagement to Mary Todd, possibly because of his affection for another woman. He was also undergoing devastating reversals as a Representative in the Illinois State Legislature, stemming from his ill-timed support of public works projects. His law practice, while successful, was becoming increasingly hectic, and his closest friend and confidante, Joshua Speed was about to marry and move away. Speed later gave an account of the breakdown:

"Lincoln went Crazy---had to remove razors from his room---take away all Knives and other such dangerous things---&---it was terrible---."

Once again, it was the supportive intervention and kindness of friends that saw him through the episode. Fortunately, this crisis proved a turning point in Lincoln's life. He arrived with clarity at a reason to live. He developed an "irrepressible desire" to accomplish something while he lived, some impact on the events of the day "...that would redound to the interest of his fellow man." In this manner, Shenk suggests, Lincoln's illness helped fuel his greatness.

An obvious question arises: given his numerous personal and political reversals, superimposed upon his underlying disposition, how was Lincoln able to persevere? Shenk devotes an entire section of the book to the conscious coping mechanisms with which Lincoln was able to actively manage his otherwise potentially lethal affliction. Of primary importance was the sense of purpose that informed his actions and moderated his manner. He was determined to make some substantive contribution to society for which he would be remembered. He recognized the importance of social engagement and had a wide circle of friends. From an early age, he cultivated the use of humor and storytelling as a means of bonding with them. He read voraciously and found solace especially in the works of Poe and Shakespeare. Finally, he openly acknowledged the fact of his suffering, and was a keen observer of his illness. He developed a theory of depression consistent in many ways with modern views. He regarded his moodiness as "a misfortune, not a fault" and recognized that he was constitutionally predisposed to the condition. He also recognized within himself three precipitants to episodes of depression: periods of social isolation, periods of high stress, and periods of bleak weather.

What relevance does the story of Lincoln's depressive illness have for emergency physicians? The lifetime prevalence of depression among physicians appears to be at least as common as in the general population (estimated at 12% and 19 % for US males and females, respectively).3,4 These figures, applied to the enrollment of the American College of Emergency Physicians,5 suggest that as many as 4,000 members might be so categorized. Indeed, a recently published reader survey from Emergency Physicians Monthly on depression and suicide among emergency physicians raises concerns about the scope of the problem. Although the sample size was relatively small (108 respondents), 73% reported having experienced significant depression, 48% considered harming themselves in the course of the condition. Strikingly, 41% reported they did not seek treatment.6

It has been pointed out that physicians with depression face a number of barriers to seeking and receiving care. These include lack of time, associated stigma, cost considerations and practical concerns regarding disclosure. Practicing physicians with known emotional disturbances may encounter difficulties in obtaining health and malpractice insurance, medical licensure, and hospital privileges. They may face, as well, unwarranted bias from colleagues, given the low priority accorded to physician mental health within the culture of medicine.7

Although framed as an example of a productive life achieved in spite of chronic depressive illness, Lincoln's Melancholy is also an account of extreme emotional pain and may well serve as a cautionary tale to those who suffer their depression in silence. Modern-day treatments are often highly-effective, well-tolerated, and readily available. Of the recommendations made in the Consensus Statement on Depression and Suicide in Physicians,7 several seem especially compelling. Physicians should establish a regular source of health care, learn to recognize depression and potential suicidality in themselves, and actively seek treatment when appropriate. Additionally, the culture of medicine must accommodate to the reality of untreated mood disorders among physicians and eliminate the barriers currently hindering the process of seeking and receiving care.

Bibliography

  1. Shenk JW. Lincoln's Melancholy. How Depression Challenged a President and Fueled His Greatness. Boston, MA: Houghton Mifflin Co., 2005.
  2. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, Washington D.C.: American Psychiatric Association, 1994, 342.
  3. Blazer DG,Kessler RC, McGonagle KA, Swarts MS. The prevalence and distribution of major depression in a national community sample: the National Comorbidity Survey. Am J Psychiatry. 1994;151:979-986.
  4. Frank E, Dingle AD. Self-reported depression and suicide attempts among US Women Physicians. Am J Psychiatry. 1999: 156:1887-1894.
  5. Personal Communication, American College of Emergency Physicians, Emergency Medicine Practice Department, 2006.
  6. Andrew LB. Survey Says: Many emergency physicians suffer in silence. Emergency Physicians Monthly. March 2006;1.
  7. Center C, Davis M, Detre T, et al. Confronting Depression and suicide in Physicians. A Consensus Statement. JAMA. 2003; 289:3161-3166.
  8. Miles SH. A challenge to licensing boards: the stigma of mental illness JAMA. 1998; 280:865.

 

 


 

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And So It Goes

Jennifer L'Hommedieu Stankus, JD

He was young and invincible
Barely finished with High School
No plans for life
Yet feeling so alive

He felt the highest highs
And the lowest lows
He lived for his car
Racing anyone who challenged

The feeling of power
Too intoxicating to let go
This was being a man
No one could possibly understand

This made him feel sexy
And full of energy and excitement
On top of the world
With nowhere to fall but down

Did he know the risks?
Several friends had died this way
Two days before graduation
He sobbed at a funeral

Counselors had come
This was a lesson, they said
That we are all vulnerable
That life is precious

Incapable of error
Uninhibited by fear
A true warrior
He threw it into gear

Racing side by side
Concerned only for self
He rounded the turn
Too late to stop


He knew the risks
His life is changed forever
The weight of the world
His to bear eternally

His conscience heavy
With the burden of a child
Who never saw the car
Racing to take his life

His conscience heavy
With the burden of the parents
Who will never kiss their child
Or see him grow

He cries in the doctor's office
Half broken and newly weak
He wants to help people understand
The risks of invincibility

He wants this to have meaning
He wants his experience
To help others avoid the risks
And so it goes…

We treat the invincible, mend the spirit
We do our best to educate
Caught in the endless cycle of repetition
Seeking invincibility to exhaustion or doubt

 

 


 

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The Wellness Section Web Page

Wellness Section

Have you accessed the Wellness Section Web Page recently? If not, here is a sampling of the contents:

  • Core Readings in Wellness for Residents in Emergency Medicine
    A survey of recent literature relating to issues of wellness in residency training.
  • Litigation Stress - A Primer
    Prepared by Louise B. Andrew, MD, JD, FACEP. An introduction to the process of dealing with malpractice litigation.
  • Wellness Section Newsletter Archive
    Quarterly issues of the newsletter dating back to September 2005.
  • Physician Impairment Resources
    A listing of organizations providing information about and/or treatment for impairment.
  • Emergency Medicine Resident Wellness: Power Point Presentation
    Prepared by Lily C. Conrad, MD, PhD, FACEP. Formatted so as to be easily adaptable for resident lectures or discussion groups.
  • Resources For Physicians in Pre-Retirement Years
    A listing of available resources for issues such as retirement planning, health and fitness topics, volunteer opportunities, and educational programs.
  • Sign-up for the Wellness Electronic List
    From time to time, ACEP and the Wellness Section send news, updates and other messages via e-mail. Also enables participating in e-mail discussions and networking with other members of the Wellness Section.
  • The Aging Emergency Physician: Recommended Health Screenings
    Based on publications of the US Department of Health and Human Services, in conjunction with a number of major specialty organizations.

 

 


 

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The Doctor

Sir Luke Fildes
The Tate Gallery
London, England

The Doctor

Sir Luke Fildes' masterpiece was commissioned by Henry Tate in 1887. The image has appeared on postage stamps in the United States and Britain, and the its use by the American Medical Association has made it an iconic depiction of the concerned and caring physician. Fildes eldest son, Phillip died Christmas morning, 1877. He was attended by a Dr. Murray, whose character and bearing so impressed Fildes that this painting was inspired. For a more complete discussion of the painting and its history, see: Gifford GE Jr. Fildes and "The Doctor." JAMA.1973;224:61-63.

 

 


 

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Reflections on Variation

Susan M. Nedza MD, MBA, FACEP

After a recent lecture on health policy for physicians, I had the great luck to find myself in an Adirondack chair looking out over a lake. The silence and solitude enveloped me as my mind wandered aimlessly. The sound of the wind rustling through the trees drew my attention to a group of nearby birch trees. The play of the late afternoon sunlight on the leaves, combined with the breeze took my breath away. I watched as the first leaves let go and fell to the ground while others continued to dance in the sunlight. I was overwhelmed by the variety of patterns and reactions that I was privileged to witness. My thoughts wandered to the infinite numbers of pattern variations possible in those four trees. It reminded me of the 1000 piece jigsaw puzzles I did as a child where your ability to complete the puzzle depended on your ability to recognize subtle variations in color and position.

I came back to the present and began to consider the challenge to define health care value that I had given the group of cardiologists only a few hours before. I had shared with them the challenge of defining quality care at a national level and encouraged them to take on the task at the local level. How difficult is that task? What could I learn from the wind and the trees?

I began to reflect upon my own experience that no two patients were exactly alike. Each patient was like one of the leaves, connected to others and dependent on its position on the tree, the roots of its host, and open to a variety of influences that affected its appearance. The response to stress by a leaf is dependent on the trees position in the forest, recent history of droughts or local infestations that can weaken it. Pre-existing social, genetic, geographic and health conditions most certainly will have a similar impact on any patient's health and their response to illness or treatment.

I drifted back to my clinical practice experience to confirm this metaphorical musing. How often had I completed a work up, only to have to go back and re-evaluate the context that the patient brought with them into an encounter? How often had their access to care, their precarious hold on health or other factors affected their outcome? How often had I actually grasped the variation that surrounded each patient encounter and affected the outcome? I was overwhelmed by the complexity of ED decision making when it is viewed within the context of variation.

A system that rewards and supports high value healthcare needs to also be focused on the variations in resource allocation as well as quality at the local level. Drs. John Wennberg and Elliott Fisher and their colleagues from Dartmouth www.dartmouthatlas.org have captured the extremes in variation seen in local healthcare markets. One of their most recent reports captured the differences in the management of Medicare enrollees with severe chronic illnesses. They found that among people who died between 1999 and 2003, per capita spending varied by a factor of six between hospitals across the country. Average utilization and spending varied from state to state, from region to region within states, and from hospital to hospital within the same regions. Spending was not correlated with rates of illness in different parts of the country; rather, it reflected how intensively certain resources - acute care hospital beds, specialist physician visits, tests and other services - were used in the management of people who were very ill but could not be cured. This confirmed other research findings that for these chronically ill Americans, receiving more services does not result in improved outcomes.

How does variation play out in the ED? One only has to think back to your last night shift and all of the individuals who presented for evaluation of abdominal pain. How many of those individuals were exactly alike? In my own career, a significant change has occurred in how such an encounter is managed. The current system that is stressed by volume does not value nor allow a physician to admit a patient for a workup or to declare themselves. In a busy ED with discontinuous care, an ED physician does not have the time to do serial exams. The need to have a definitive diagnosis does not allow the physician to call for a consult based upon purely clinical findings. An often confounding factor is a lack of or limit to access to primary care for follow up in many communities. The result in the confluence of these factors is not a surprise. 

One can partially attribute the current rise in the utilization of imaging across our practices to CT being utilized as a screening and diagnostic tool. One can't argue with the supporting data or information that it can provide. However, it can't be utilized in isolation without knowledge of the risk factors, advanced directives, co-existing conditions, physical manifestations and historical data that allows for appropriate interpretation and risk-stratification. The famous disclaimer "clinical correlation is advised" still holds true and is necessary for informed decision making. This speaks to policy decisions that emphasize and value processes at the individual level and providing rewards for such integrated decision making.  It is the variability that is linked to the patient, the physician's training and experience, and the availability of local resources that results in variations in practice and must be understood in defining systems, measures and rewards.

So is it fair to challenge the physicians to define value at the local level? My experience that afternoon confirmed the fact that this is crucial if we are to get it right. Value is created through the interaction at the bedside when all parties understand context and complexity. Value is created when incentives foster the ability to utilize technical, professional, intellectual, and health system resources to drive good decision making. I felt sure that I had been correct in defining the challenge as one related to how to create value in their practices.

My work done, I reluctantly left my seat beneath the trees.  I committed to spend more time in reflection and in studying patterns in search of insight through contemplation and silence. I highly recommend it for all of us with busy lives who know too well how easy it is to lose sight of the forest for the trees.

 


 

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An Antidote to Stress

Mozart's Clarinet Quintet is the second of the three great works he wrote for his friend and fellow-freemason, the clarinettist Anton Stadler. Stadler was the principal clarinettist of the court orchestra in Vienna, and seems to have been an artist of remarkable gifts - one Viennese critic wrote of his playing that "I would not have thought that a clarinet could imitate the human voice so deceptively as you imitate it. Your instrument is so soft, so delicate in tone that no-one who has a heart can resist it." Stadler's playing was clearly an inspiration to Mozart, and the clarinet consequently took a place in his affections second only to the viola. Clarinets give a distinctive, very personal character to such works as the A major piano concerto (K.488) and the Requiem (K.626), and the three masterpieces in which the clarinet is the principal instrument - the concerto (K.622), the "Kegelstatt" Trio (K.498) and this quintet - stand apart from the main body of Mozart's work by virtue of their expressive intimacy. Of these, the Quintet is outstanding for the sensuous beauty of its tone colours; the exquisite subtlety with which Mozart mixes and contrasts the sounds of his five instruments.
SOURCE: www.classicalnotes.co.uk

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Wellness Section Meeting Minutes - 2006 Scientific Assembly

Morial Convention Center
New Orleans, LA
October 15, 2006

Participants

Committee members participating included: Section leaders and 16 section members and guests.

Others participating included: Angela Gardner, MD, FACEP, Board Liaison; Marilyn Bromley, RN, Staff Liaison; Rhonda Whitson, RHIA; and Cal Chaney, JD, CAE.

Agenda

Welcome
Review of Section Activity
Election of Officers
Presentation: Wellness on the Web
Installation of Chair for 2006 - 2007
Open Forum - Discussion
Adjourn

Major Points Discussed

Dr. Goldberg opened the meeting by welcoming everyone and providing an update on all the section had accomplished this year. He noted that wellness materials had been submitted to residency directors to use in their programs and wellness materials had been submitted to chapters to include in their newsletter. The section Web page has been updated and many new pieces of information and articles were added. A wellness annotated bibliography had been included.

It was reported that the section had received an unprecedented 2 grants for this section year. One grant will survey 1000 members in the pre-retirement years to learn more about the concerns and issues they are facing. The other grant will look at emergency physician's ability to deal with uncertainty.

Election of officers was done by acclamation.
Chair-elect - Julia Huber, MD, FACEP
Secretary/Newsletter Editor - Julia Huber, MD, FACEP and Richard Goldberg, MD, FACEP will share the duties.
Councilor - Mitchell Cordover, MD, FACEP
Alternate Councilor - Rochelle Greenman, MD, FACEP

Dr. Goldberg provided an informative look at the variety of information and websites available that you can use to improve your health, fitness and receive the latest information on everything from diets to what clinical trials are available.

General discussion included the need to recruit more residents and young physicians to the section. The section looked at ways they could make the section and the topic of wellness relevant to them. A resident attending the meeting indicated a willingness to write a brief piece from the resident's perspective. It was also suggested that for those in the audience that worked with residents that they provide membership in the section for them, or encourage those eligible for free membership in the section to select Wellness. It was asked that if a resident didn't select a free section if consideration could be given to have Wellness be the default free section. Audience members discussed the universality of wellness and how physicians can not start too early in their career being aware of the need to be knowledgeable about wellness and its applicability to the various stages of life and career.

It was noted that the reconfiguration of the booth was a great hit, and traffic was moving well as members sought services.

The members wondered if it would be feasible in future years to consider having a 'quiet room' at the convention center for members sit, rest and be away from some the hustle of the crowds. Additionally a request was made for consideration of an area for nursing mothers and those that need to pump breast milk. It was felt that public restrooms were not conducive to this activity and pumping required an electrical outlet.

 

 

 


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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.

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