Archives for February 2010

MD Whistleblower: Whistleblower Grand Rounds Vol. 6 No. 22: It’s ‘Alimentary’, Doctors!

It’s been a while since I’ve attended a conventional medical Grand Rounds. These were events where a medical luminary would fly in to give a medical audience a state-of-the-art presentation on a medical subject. Ideally, the speaker was a thought leader and a researcher on the issue.

These presentations were usually not a demonstration of the virtue of humility. We physicians, as a class, have generous egos. Academic physicians occupy a higher rung on the ego ladder. Medical Grand Rounders (MGRs), who are on the GR speaking circuit, often must bring their own ladders to assure they will be able to reach their desired atmospheric height.

via MD Whistleblower: Whistleblower Grand Rounds Vol. 6 No. 22: It’s ‘Alimentary’, Doctors!.

Grand Rounds is up, with the longest preamble in GR history.  Another first!

ABEM is over-reaching their role

The American Board of Emergency Medicine (ABEM) describes itself as:

Welcome to the American Board of Emergency Medicine (ABEM) public website.  ABEM certifies qualifying physicians who specialize in Emergency Medicine and is a member board of the American Board of Medical Specialties (ABMS).  ABMS certification is sought and earned by physicians on a voluntary basis. ABEM and other ABMS member boards certify only those physicians who meet high educational, professional standing, and examination standards.  ABEM and other ABMS member boards are not membership associations.

The thing I’d like to bring your attention to is that it’s a Voluntary organization.  For a voluntary organization they’re adding lots of requirements without asking members…

Since most of you don’t know about Board Certification, it’s a way for doctors to demonstrate (mostly to their peers and employers/hospitals but also to patients) that they not only finished their residency, but paid attention and learned enough to pass the Board Certifying exam.  Yes, it’s possible to be a doctor, finish a residency, but not pass the board exam and have a nice lifelong practice anyway.

I’m Board Certified by ABEM, which required completing an accredited residency, passing first a written then an oral examination.  Okay, I’m done, right?
Emmm, no. I’m BC for 10 years.  In order to re-test to be BC for another 10 years, I have to take (and pass) yearly tests over medical literature, tests payable to the ABEM.  Which ABEM didn’t bother to figure out how to give us CME credit for.  Genius.

Imagine my surprise at ABEMs’ latest addition to hoops to jump through to maintain my Board Certification: the Assessment of Practice Performance.  In a nutshell: show ABEM that 10 patients didn’t hate my medical performance, prove that on 10 hand-picked charts I’m keeping up with published treatment benchmarks (like aspirin for ACS, antibiotics in 6 hours for pneumonia, etc), and self-certify the same to ABEM.

While that’s easily doable for me at Giant Community Hospital where I work (we already keep track of this, and a lot more), it’ll no doubt be harder for very small ED’s.  I agree this sort of performance thing needs to be tracked, and practice outliers nudged back toward the middle, but what on earth does this have to do with being Board Certified?  Where in ABEMs’ mission statement does it say they’re going to certify we’re practicing on par?  Nowhere.

This would be an entirely different argument if Board Certification were required for employment in EM (it’s not), at my hospital (it’s not), in my group (not), exempted me from any state CME requirements (doesn’t), increased my pay (doesn’t), you get the idea.  That’s a lot of work to keep a voluntary certification that gives me back… nothing tangible.  Oh, I’m a Diplomate of the American Board of Emergency Medicine, and with that and $6 I can get coffee almost anywhere.

I find it interesting there’s not much push-back on this new requirement.  ACEP’s President-Elect ‘interviewed’ ABEM President Debra Perina about this latest addition, uncritically and without any challenge: EM Leaders Discuss ABEM’s Maintenance of Certification Program.

To paraphrase the question, why? The answer:

SS: Is it correct to say that the public is asking for more accountability regarding continuing medical education, even between board examinations?

DP: That’s correct. I know that ACEP and the emergency medicine community have been following testimony in House and Senate hearings from consumer advocates requesting assurances that physicians remain competent throughout the course of their practice. The public is questioning boards that test sporadically or in some cases offer lifetime certification.

Hmm.  I genuinely understand the desire of the public to make sure docs are keeping up, and practicing inside norms (and this is not asking for a flaming: I’m aware there are docs who give amoxicillin for everything imaginable, who don’t keep up, etc) but this is a) window dressing on that front and b) if meant to serve as some reassurance to the public, it’s inadequate, at best.

But that’s really beside my point, which is that it’s not ABEM’s role to make certain my practice is up to par, that’s the role of, ultimately, my State (which licenses me) and my peers, who have a lot more impact on my practice than the ABEM.  ABEM should document that the provable (I’m keeping up with my certification, meaning the every 10 year tests, grudgingly the yearly tests*), and that’s it.

In an upcoming rant: competition is good, is it way past time ABEM had some legitimate competition from another Board Certifying organization?

*In either the first or second year of these yearly tests, the article being tested was about Neseritide, which in the article was the best thing for CHF since phlebotomy.  Of course, by the time we were being taught/tested on it, Neseritide was out of vogue as it hadn’t worked out in practice as it had in studies.  But, you had to give the currently wrong answer to the test.  Pitfalls of keeping up through testing.

Even the ladybug doesn’t get it

It’s a 45 round from a factory box of Fiocci ammo. The round is loaded pointy end first.

Trauma no longer defined as a Surgical Disease

In Annals of Emergency Medicine today (Volume 55, Issue 3, Pages A20-A24 (March 2010):

The new 8th edition of the Advanced Trauma Life Support (ATLS) course manual1 contains a small but significant change. The phrase, “trauma is a surgical disease,” long a point of contention with other specialties caring for trauma patients, has been removed.

John B. Kortbeek, MD, FACS, professor of surgery and critical care at the University of Alberta and a member of the COT who was instrumental in the revision process for the manual, confirms that the deletion is intentional.
Dr. Kortbeek explains the change in historical terms. “The intent of making that statement,” he says, “was to emphasize that to have a successful trauma system and a successful trauma hospital, surgeons needed to be included in the management team and the care of the trauma patient. That remains true today. What changed over time is that that statement became a focal point and could be interpreted in varying ways, including in a negative, exclusive way, suggesting that only surgeons should be managing trauma patients, which is not correct and never was the intent of the statement.” The ATLS, he says, presents a “common language” for a safe and effective response to trauma, not a mandatory formula.

Hmm. Our Trauma Center is going to be surveyed soon, and at the last survey we were told Trauma needed to admit All Trauma. A sea change occurred, and they did. Now this.

And not everyone needs a rectal exam? Surgeons are getting soft…

Heh. Some things haven’t changed:

One source of unnecessary friction between fields, Dr. Green notes, is that the ATLS minimizes the role of emergency physicians and offers no explicit recognition of emergency medicine’s expansion and maturation as a specialty over recent decades. “One thing that hasn’t changed in the manual, which has always been kind of a source of irritation to emergency medicine, is throughout the entire ATLS student manual, a big thick book, the phrase ‘emergency physician’ never occurs. We are like the ghosts of trauma care. Everything is oriented around the surgeon. It’s as if we don’t exist.”

» Features » Soundtrack for the Emergency Department.

» Features » Soundtrack for the Emergency Department..

The ED Main Theme.  Impacted nurse has skills, and apparently too much time on his hands…

Looks like it’s be catchier then the theme song to the TV show ER…

oncRN: fyi

i have yet to meet a patient who wants treatment.

patients want an outcome.

big difference.

via oncRN: fyi.


I had a patient with an inoperable tumor recently, who’d been getting chemo and radiation for this same tumor for 4 years, while it progressively got bigger and bigger, all nicely documented in the electronic notes.

And, when I advised a hospice admission I was rebuffed.  “The oncologist says we might be admitted to an experimental treatment at MD Anderson”.

I understood their desire to have hope (however misplaced), and wanted to throttle an Oncologist.  We’re talking about a bone invading tumor the size of a soccer ball.  Which has responded to exactly nothing, in  years.  At what point is treatment not only pointless, but counterproductive?

(Old doctor joke: when the nephrologist goes to the morgue to give the last dialysis, they’re surprised to find a note in the empty coffin “gone to chemo”).

We all want to live forever.  None of us will.  Don’t give up when the treatment can give a positive outcome; don’t waste your days chasing treatment when the outcome is more treatment…

thanks to Musings of a Dinosaur for the idea, and OncRN for the insight.

The Laurinburg Exchange – Shooting at Scotland Memorial Hospital

Scotland Memorial Hospital was locked down Monday morning after a shooting left a patient in critical condition and another man in police custody.

The 3 a.m. shooting appears to have stemmed from a brawl at a McColl, S.C. night club, according to Laurinburg police. Authorities say it involved the victim, his girlfriend and the daughter of the shooter just a few hours earlier….

via The Laurinburg Exchange – Shooting at Scotland Memorial Hospital.

This exact scenario is why most hospitals have some system to anonymize victims of violence in the ED, and sometimes throughout their hospital stay.  (We have one, and I’m not letting its incredibly complex code out…).

That doesn’t make them either invisible or bulletproof, and we’ve seen a few examples of our trying to anonymize them gone wrong when their ‘friends’ start calling and texting once in the ED.

I’m happy no ED employees were injured, and hope the alleged attempted murderer gets a fair trial and the punishment deserved.

Also, don’t get in bar fights…

HT: Glen in West Texas, my news machine

  Doc Gurley – Haiti Journey: Hitting the ground — Doc Gurley

Doc Gurley – Haiti Journey: Hitting the ground — Doc Gurley.

Doc Gurley’s in Haiti.  Will be fun to follow her.

Texas Party of Medicine

Early voting starts today in Texas (Feb 16-26) with Election Day being March 2nd.

TEXPAC (The Texas Medical Association PAC) releases a roster of candidates every major election, and this one’s no exception: 2010 Election Primer (as a .pdf file)

The only easy pattern I can discern is that all the court races are “R’s”, if that helps.

As they say in Politics, vote early and often…

richard[WINTERS]md: Skipped a beat.

The handle bar of the snowmobile fractured his ribs.

Nice guy. Mid-60s. Talkative and generous in his remarks.

It occurred yesterday. He thought it would heal by itself.

Didn’t want to bother us. But now he was a little breathless.

His lung was punctured. His skin was full of air. It crackled and popped as I rubbed the betadine on his chest in preparation for the procedure….

via richard[WINTERS]md: Skipped a beat..

He doesn’t post much, but when he does, it’s usually good.

Please check it out, and if you like it, leave him a comment you came from here, and thank him for getting me into blogging…

I’m going to make a button to wear at work

It’ll say “I’m really only a dick at work”.

I’ve written before about my ‘game face‘ and how it’s not me, not really.  It’s a Business Me, and it’s how I get through life at work.

(Is that a cop-out? Do I do it because it makes me more efficient, a better doctor, smoother, faster, or do I do it because it builds a bit of a wall between me and my real self and lets me get through the day without getting emotionally attached to every patient and their family?)

I’m tolerable at work, but not really lovable, and I’m okay with that.  The persona I have is what I’ve made it, and it works for me.

I was told by new faculty (fresh from 10 years a Kaiser, in my last 6 months of a 4 year ED residency, so I was arrogantly dismissive of a guy I should have sat at the feet of) that ‘you’re going to be the center of the world’ and I didn’t believe him.  3 months later fending off every single problem imaginable (parking, who gets what meals, ‘will you look at this EMS patient that’s a direct admit but you’re available and we want to involve you’, paperwork by the pound, etc) I made some changes to the Things I Will Do Gladly list, and started the lifelong project of pushing back on those things that aren’t necessary for me to be involved in.

Approachability is the key in this transformation, and it’s a fine line letting the staff know what I expect them to handle and when it’s time to come get me.  This means No Barking, a lot of education and the occasional growl.

I’m kidding myself about the button.  It’d just be for me.  I’ll wear it on the inside of my coat.

Though I may get a booth and sell them at the ACEP Scientific Assembly; I think there’d be a market amongst my ED colleagues…

The Hindu : News / International : Frisbee inventor Walter Fredrick Morrison dead

Walter Fredrick Morrison, the man credited with inventing the Frisbee, has died. He was 90.

via The Hindu : News / International : Frisbee inventor Walter Fredrick Morrison dead.

I’d rather throw a Frisbee than a ball any day.  Unless it’s windy.

via Scanman | Call me corpsman, call me ‘Doc’

Perhaps to the surprise of some, I won’t blast President Barack Obama on his inability to pronounce the word “corpsman” (which he pronounced “corpse man”). Instead, I’d like to take the opportunity to give much-needed praise to Navy/Fleet Marine corpsmen who are, as you will see, a special breed of warriors.

via | Call me corpsman, call me ‘Doc’.

Nice article by a former Corpsman. | When you die, doctor…

This is a sample section from a new book I’m writing on the transition from residency to practice.

When you die:

via | When you die, doctor….

More astonishingly good advice from Dr. Leap.

Four Arizona doctors surrender their licenses – Phoenix Business Journal:

The Arizona Medical Board accepted proposed consent agreements for surrender of license from four rural Arizona physicians who admitted they had committed unprofessional conduct and agreed to the disciplinary action.

via Four Arizona doctors surrender their licenses – Phoenix Business Journal:.

Wow.  I’d hate to have to give up my license.  When I read these I wonder what the full stories are…