ABEM and their new POS TOS

A guest post! (Finally, a use for my blog)!

So there I was, just cruising the Internet, when I thought to myself, “Jeepers! It’s about time I checked on my ABEM Maintenance of Certification status! Golly, I might be late for the latest LLSA!”

Well, not really. But anyway, there I was on the ABEM website, when I ran into this rather odious new “click here to consent” barrier (see below).

Most of it was pretty standard – I certify everything is true, I won’t cheat on the exam, I won’t share test questions – OK, fine. Then we get to the particularly unsavory bits:

1. a mandatory arbitration clause.

This is a big deal, especially with the whole hubbub with ABIM and their MOC controversy. Essentially you are waiving the right to sue ABEM and must turn things over to an arbitrator, who is almost always going to find in favor of the big company and not you, the individual. And oh by the way, if there’s a dispute, you have to schlep out to Ingham County, Michigan to do this arbitration – not in your home court system.

No me gusta.

Here’s some information on why mandatory arbitration doesn’t benefit you:

TL;DR: pre-dispute mandatory arbitration is biased towards the larger organization and should be avoided at all costs. Given that ABEM is made up of us, the emergency physicians, we should be able to tell our specialty board to take their arbitration clause and shove it.

2. mandatory personal information sharing with Elsevier’s for-profit “Official ABMS Directory”.

The other part that I find undesirable is the mandated information sharing. I hate getting 15,000 tons of locums spam, advertising, and a bunch of other garbage in either my home or my work mail box, to say nothing of the ‘helpful’ phone calls and emails from headhunters trying to fill an EM job in BFE.

And yet, ABEM is mandating that we share our personal information with Elsevier – to then publish in in a for-profit “doctor’s directory”?

To put it bluntly – EFF NO.

I’m an emergency physician. I don’t need to advertise. I don’t need to have people “looking me up” to see if I’m board certified. And oh by the way, I don’t have an “office” – so I use my home address for most of my certification stuff. I definitely don’t want that info out in public, especially given the casual disregard to privacy that is all too prevalent today. In my opinion, the less personal information shared, the better.

But there’s NO WAY to opt out of this information sharing. Emailing or contacting Elsevier goes nowhere. We’ll see what happens with ABEM.

Quite honestly, I find that overall, there’s little regard to doctors’ privacy, because people think “oh, you want people to find you so you get more business”. No, I don’t – not in our specialty. People find me just fine – they look for the big blue H sign on the highway, or the brightly lit sign that says “EMERGENCY – Physician on Duty”. I don’t need ‘helpful’ directories to publish all of my information.

I’ve sent out an email to ABEM, at abem@abem.org and moc@abem.org. You should too.

Let’s fix this before it gets out of control.

Sameer Bakhda, M.D.
Monterey, California
Twitter: @sameerucla


(Many thanks to Dr. Bakhda for the post! FYI, the title is mine, so blame me for that.)

How ER docs actually process what we do

A remarkably good blog post from Seth Treuger ( @MDaware on twitter).

The classic model of history, physical, testing, diagnosis & treatment does not apply to us. I think we do 3 things in emergency medicine:

  1. Resuscitation
  2. Risk stratification
  3. Care coordination

Resus is the fun sexy stuff that we stay up late at night having twitter arguments about. As much as I love ketamine, I can go a number of shifts without using it, and very little of what we do is resus. Most of what we do is risk stratification and care coordination.

Read it. It’s good.


33 Charts — medicine. health. social media.

Well put!

After a recent presentation on social physicians, someone asked why there were so many emergency medicine physicians on blogs and social media?  Good question.  From content to conversation, ER docs are heavily represented in public spaces.  And it’s as much about passion and participation as raw numbers on any given platform.

What is it about emergency medicine physicians that has lead them to flex their muscles and reach out beyond the confines of their emergency centers?

via 33 Charts — medicine. health. social media..

Yrs. Trly. gets a mention.

Facebook Like Now Covered by the First Amendment – Applications for Healthcare | Hospital EMR and EHR

This is at the end of an article talking about something else, but it deserves it own highlight:

My favorite thing is when healthcare organizations try and control and restrict social media. As many institutions have learned, that’s impossible to do. Instead, it’s much more effective to educate and inform people on their use of social media. The best reason you should educate and inform as opposed to control and restrict is the message it sends to your employees. The former sends a message of trust and respect while the later does the opposite.

via Facebook Like Now Covered by the First Amendment – Applications for Healthcare | Hospital EMR and EHR.

Well said.

What doctors should look for in job seekers’ social media presence – amednews.com

Don’t make yourself unhireable.

As the medical director of a health services group that serves racially diverse patients in some of Chicago’s poorest neighborhoods, Ravi Grivois-Shah, MD, always conducts a quick search of physicians he’s interested in hiring on various social media sites and blogs to see if anything worrisome surfaces before offering them a position.

via What doctors should look for in job seekers’ social media presence – amednews.com.

SoMe is entertaining, but here’s the equation we should all keep in mind: Job >>>>>> SoMe.

You’re welcome.

ACEP 12 tweeting: Bukata and Hoffman

Those who don’t follow me on Twitter probably have calm, productive lives. Those who do wonder why I twitter at all. Because it keeps me busy and engaged, that’s why.

Here’s an edited compilation of two of the American College of Emergency Physicians Scientific Assembly 2012 lectures in tweets by me from Denver. These encompass about 3.5 hours of lecture by the same two legends, Jerry Hoffman and Rick Bukata reviewing the medical literature as it applies to EM.

I used Storify to put these together (it couldn’t have been easier). I left out a lot of comments from others, not as they weren’t interesting but as I’m trying to tell the story of this lecture.

At the end there’re some pictures of the Twitterers and Bloggers who get together after ACEP. Nice how we’re birds of a feather. For a bonus, at the end are Joe Lex’s 4 Rules of Emergency Medicine, which deserves its own compilation.

ACEP 2012 Tweets by me: Hoffman & Bukata

I went to the American College of Emergency Physicians Scientific Assembly held in Denver in October, 2012. I live tweeted some of the lectures I attended. Here they are.First, I’m going to combine the tweets from Hoffman and Bukata’s 2 lectures, as they’ll make more sense that way. Then pictures!

Storified by GruntDoc · Sat, Oct 13 2012 12:55:37

I’m going to start with my general Twitter disclaimer. I mean it.
Disclaimer: my tweets from #ACEP12 were paraphrasing, errors mine, don’t change practice based on reading tweets, do your homework.GruntDoc
And, off to the lectures:
HofKata: Trauma surgery is dooming their specialty going to the ER over and over for nothing surgical for them. #ACEP12GruntDoc
Referencing a European paper citing very very few went to the OR emergently from the ER to the OR, recommended calling TSS when the ER doc needs them, not a routine event.
(Will not catch on for a long time, Trauma needs their Activation Fee).
This following one had to do with ?whatever to do with those very tiny occult pneumothoraces we’re finding on trauma CT’s of the chest. Long, meandering discussion; sizes of the PTX weren’t defined, no criteria for getting a thoracostomy tube were made, just ‘did they get a chest tube or not’.
HofKata: discussion muddied as there is not a clear definition for want made the doc put in the tube to start with. #ACEP12GruntDoc
Not much was gotten from that article. Perhaps I missed the point.
HofKata: docs caught between doing what’s right for pt and right for doc; for doc getting test is right answer, not always for pt. #ACEP12GruntDoc
This next one tried to determine, in a ‘pan-scan’ for trauma ED, if there were some agreement on what trauma scans the ED attending and the Trauma Surgery attending could prospectively agree they didn’t need.

All the scans trauma wanted were gotten with a prospective form filled out by both about which scans they didn’t want. In the end the ED…

HofKata: wanted 30% fewer, and the TSS and EM in the end couldn’t decide about the value of the discovered incidentalomas. #ACEP12GruntDoc
They found a bunch of incidental things, and in the end couldn’t reconcile whether finding completely incidental things that didn’t affect management was worth the CT.
HofKata: factor VIIa is 10k for a 70kg pt in trauma and it didn’t help ( the non hemophiliac). Stop it. 97% uf use was off label. #ACEP12GruntDoc
HofKata: if you have 1 CT the likelihood is that you’ll have 5 in the next 5 years. Found a pt w 57 CTs. Wow. #ACEP12GruntDoc
The first CT is a gateway study to more, apparently.
HofKata: but when docs look at the same problem for themselves they typically choose less awful treatment, even if means pal care#ACEP12GruntDoc
Doctors will err on the side of survival in recommendations to patients, when they themselves often look at the data and decide they’d rather forgo some or all treatments and skip the unpleasant effects. Interesting.
HofKata: DC instructions. Pts have to understand, and they have to know when to come back. Ethical prob sending self limited prob #ACEP12GruntDoc
HofKata: to a referral, when its more cost for no benefit. #ACEP12GruntDoc
Bukata felt sending things like ankle sprains to PCP’s as a routine thing was ethically bad, as ‘it’s self limiting’ and costs the pt more for no benefit.
I disagree, many needs some Physical Therapy to have a more stable ankle that doesn’t recurrently sprain.

Also not a fan of these 9 page DC instructions we’re printing out.

HofKata: IO lines are great, and stop doing central lines because you can’t find a vein, use CL if need to measure things #ACEP12GruntDoc
HofKata: no need to give hydrocortisone if you use etomidate for induction. (Silly study). #ACEP12GruntDoc
HofKata: Tylenol w Motrin, and either alone. Point of treating fever comfort, not medical. No support to use both at the same time #ACEP12GruntDoc
HofKata: AAP specifically advises against using Tylenol then Motrin and alternating, confusing. Also, tells mom it’s a big deal. #ACEP12GruntDoc
treating pedi fever is about patient comfort, not treating disease. making a big deal out of fever treatment tells mom it’s very important, when it’s for comfort only.
HofKata: UTIs in small kids: can have asymptotic bacteruria and have a viral illnesses w fever and get dxd w uti. Cults have false+ #ACEP12GruntDoc
HofKata: 2-5% of kids have UTIs before puberty. Not happy about treating a ton. #ACEP12GruntDoc
Many of which were incidental findings, and the treatments can cause their own problems.
HofKata: study of 1,228 acute scrotii showed +creamasteric reflex w dxd torsion! 7% had NL or increased flow on US!? #ACEP12GruntDoc
Several people disliked my plural of scrotums being scrotii. I believe scrotae is the correct plural.
HofKata: test torsion, cont: advocates getting a iron consult for those w real sx’s and a negative w/u. Then cites anecdote. #ACEP12GruntDoc
uro(logy) got autocorrected here to iron, No idea why.
HofKata: study of Canadian hosp quick response teams. No difference. Things that seem reasonable often don’t work. #ACEP12GruntDoc
HofKata: several papers, PCR tests didn’t change abx rxing, CRP in URI resulted in 6 hour ED stays and no change in abx Rx, etc #ACEP12GruntDoc
Things being tried to tailor or eliminate antibiotic prescribing don’t. At least not in these studies.
HofKata: docs are reluctant to abandon disproven practices "ESP when lucrative". Most standards of care have never been studied. #ACEP12GruntDoc
HofKata: BNP for dyspnea in the ED. "Routine testing is of no benefit". Targeted okay. #ACEP12GruntDoc
HofKata: high sens Troponins: markedly higher positives, but 90% were causes other than AMI. (I don’t know want this). #ACEP12GruntDoc
Joe Lex ( @JoeLex5 ) commented on this later, ‘you mean low specificity troponins?”, rather than the as-spun high sensitivity. He’s right.
Touché, I’ll remember that. “@JoeLex5: @gruntdoc You mean "low specificity troponins," of course.” #ACEP12GruntDoc
HofKata: stable angina, med mgmt vs stenting: medical therapy on top for everything x persistent pain. #aGruntDoc
HofKata: the US spends 150mil A DAY on angiosperm and stents, most never had a trial of med therapy. #ACEP12GruntDoc
Okay. for some reason the iPad autocorrect thought Angio meant angiosperm, which is weird. I don’t type well, things are flying by, and so I didn’t proofread that one before I hit send. (there were several comments later which I didn’t get, so didn’t play along)(It was busy in there, with all the tweeting and misspelling).
HofKata: shocker: STEMI pts needing transfer for PCI didn’t get transferred within 30 minutes. Median time was 64 minutes. #ACEP12GruntDoc
Bukata said they fixed this at his joint by having the same EMS crew that brought them in take them out, which was very fast, and with the right conversation EMS was all over it.
HofKata: if you can get to the cath lab in less than 4 hours its better than TPa. The 60 min rule for TPa is based on no evidence. #ACEP12GruntDoc
HofKata: then says he’d rather have TPa than stenting. (Weird). #ACEP12GruntDoc
The weird was mine. I don’t get that.
HofKata: 124k STEMI pts w CABG capability did cath then CABG 3%, without very rare. CABG grps did worse. #ACEP12GruntDoc
Wow, confusing tweet.
Issue was, is it safe to do caths in places that cannot do ‘rescue CABG”? In a study of 124K pt’s in centers with and without ‘rescue CABG’ ability, answer was yes, and in places that could do CABG it was done a whole lot more than places where it wasn’t; occasional pt had to be transferred to CABG place, but not many.
HofKata: ABCD2 score for stroke after TIA isn’t reliable. Another data dredging tool fails in real life. #ACEP12GruntDoc
HofKata: redefinition of Tia w MRI findings of infarct to stroke makes both groups look better: makes studies over time hard #ACEP12GruntDoc
Way more ‘strokes’ are now very minimal (what we used to call TIA’s) so the ‘stroke category looks better, and the TIA category looks smaller. Will confound studies looking both directions.
This next one it a review of IST-3, the never-ceasing desire to give TPa to every stroke no matter the time elapsed.
HofKata: IST-3 showed in a no blinded study using untrained family members as evaluators showed a tiny trend to improvement. #ACEP12GruntDoc
HofKata: IST-3 the first 300 pts evaluated by neurologists showed the tpa out to 6 hrs is much worse. #ACEP12 scathing editorials yesterdayGruntDoc
Family members, who knew whether or not their loved one got the TPa were asked by postal mail to evaluate their loved ones’ recovery, trended better for those who got TPa. Bizarre study bias built it. To say they were unimpressed would be an understatement.
HofKata: shocker: TPa for people with dissection causing their strokes do poorly. #ACEP12GruntDoc
“@gruntdoc: HofKata: shocker: TPa for people with dissection causing their strokes do poorly. #ACEP12” surprise surpriseJennie
HofKata: Geriatric and dizzy with a normal neuro exam will not have ICH. Based on a paper from 1998 w 4 pts found to have cblr bld. #ACEP12GruntDoc
There’s a practice that’ll be hard to change.
HofKata: no decent studies on ischemic stroke leaving BP up or the older lowering. Unless going to give TPa. #ACEP12GruntDoc
HofKata: kids w brain rumors typically represent w recurrent headaches, etc. authors rec scanning in kids w recurrent ha. #ACEP12GruntDoc
Means, don’t scan a kid on first HA or first week of HA.
HofKata:Canadian SAH CT study w 3rd gen scanner didn’t LP 50% of the pts in study. Gold std was pos CT. 30% lost to f/u. LP for SAH #ACEP12GruntDoc
HofKata: says Dr Newman who presented this paper yesterday as not needing LP is incorrect. #ACEP12GruntDoc
This could be ACEP’s first Pay Per View smackdown, Hoffman vs. Newman on this Canadian CT for SAH study.
HofKata: accumulating evidence quinolones can cause neuro sx’s. still safe drug as denominator is vast, but be aware. #ACEP12GruntDoc
HofKata: giving reglan over 15 vs 2 mins decreased the akathasia. 7% vs 26%. #ACEP12GruntDoc
Turkish study, makes sense.
HofKata: CO poisoning. Hyperbaric didn’t help, showed no benefit over high flow o2. Small study. #ACEP12GruntDoc
HofKata: studied on neurosurgeon, 1/2 sit vs stand on first postop visit. Again, pts like the seated visit. #ACEP12GruntDoc
Shocker here was that this was timed, it was these NS pt’s first post-surgical visit, and they lasted about a minute and 10 seconds. Wow.
HofKata: 8% of German studies eligibility criteria weren’t included in the paper,13 published modified info. Can’t extrapolate1/2 .#ACEP12GruntDoc
HofKata: 2/2 those findings to groups that were excluded. Theme is that funded studies seem to play fast and loose w reporting. #ACEP12GruntDoc
Throws a lot of what’s published into doubt, and when they don’t report excluded groups we assume their results are applicable for the general population, which isn’t correct.
What about the deep dive into the study information that’s given to the FDA from drug companies, that’s easily digestible, right?
HofKata: Cochrane authors report that it would take 2 FTEs 14 months to analyze, and found things never addressed in the papers. #ACEP12GruntDoc
The papers mean the studies that get publishe in journals. Not getting the whole story.
HofKata: Cochrane cont: the US FDA wouldn’t give the data, had to get from AUS. puts a lot of the publications in doubt. #ACEP12GruntDoc
This was about the new ‘high sensitivity’ troponins that are about to come out, for what reasons none of us in EM can discern, as it absolutely isn’t helpful…
Touché, I’ll remember that. “@JoeLex5: @gruntdoc You mean "low specificity troponins," of course.” #ACEP12GruntDoc
Thanks, but I just tweet it. The glory goes to the lecturers, some were phenomenal. “@fayazg99: @gruntdoc fantastic stuff!” #ACEP12GruntDoc
Great coverage! RT @gruntdoc: That ends the lectures for me for today. Hope you enjoyed my coverage.Doc Gurley
@docgurley Awww, shucks ma’am. *tips hat*.GruntDoc
Meeting the social media twitter and blog greats at #ACEP12 @emcrit @gruntdoc @drrwinters @movinmeat @EMDocBrett http://pic.twitter.com/D6dLKId3Alexei Wagner
@JoeLex5 s 3 rules of emergency medicine:1) the nurse can hurt you way more than you can hurt themGruntDoc
@JoeLex5 s 3 rules of emergency medicine:2) you will never waken someone with narcan that you will like more awake than asleepGruntDoc
@JoeLex5 s 3 rules of emergency medicine:3) the LP target is always 1cm deeper than you think.GruntDoc
@JoeLex5 s 3 rules of emergency medicine:4) bonus: if you really don’t want someone to elope, hide their shoes.GruntDoc
“@gruntdoc: All the twitterers from #ACEP12 in one place. The rest of you are safe. For now. http://pic.twitter.com/j8i2uwb0” Wish I was there….realEDdoc

HCC Blog calls it quits

Dear Readers,

It has been my pleasure over the last 4 years to blog on HCC-related topics and exchange ideas with many of you. I have learned a ton from everyone.

This is my last post and I anticipate retiring the blog by the end of the month.

via HCC Blog » hccblog.

Another good blogger taps out. Too bad.

We Are All Criminals Now : PANDA BEAR, MD

Panda has resurfaced.

This is not a Panda that eats bamboo, but from all appearances feasts on spleens. Angry ones.

In fact, I was once texting while standing at the nursing station and some supervisor of something-or-another told me that cell-phones were not allowed and then looked on in helpless fury as I laughed and took his pictures to text to my friend. This is a good way to make enemies and I’m sure I’m going to be the first one up against the wall when “Papa Doc” Press Gainey is installed as out Great Leader and Ruler for Life but I did not come through the irritating hell of medical school and residency to be scolded by a bureaucrat like some wayward candy striper.

via We Are All Criminals Now : PANDA BEAR, MD.

I wish I wrote that well.

Suture for a Living: Changes

Wow. Imagine stopping being a surgeon. It’s such a part of your life, your identity.

Due to many things, I will be closing my practice over the next few months and going to work for the Arkansas Disability Determination Services DDS. I only recently made the final interview and signed the contract. My first day there will be October 3rd. I don’t want to discuss the reasons, but I want you to know how difficult a decision this has been for me.

via Suture for a Living: Changes.

We’re lucky she shares what she does with us, and I hope someday she can tell us what happened, if only to give courage to other docs looking at a career transition.


Best of Luck, Dr. Bates!

Beyond the Clinical | Learning To Be A Better Physician Leader

My friend, who got me into blogging a long time ago (you can and should blame him) has started a new effort. “Beyond the Clinical“.

How I Missed A Large Tumor and How You Will Too

He had severe right chest and shoulder pain.

His doctor had said it was the tunneled dialysis catheter. “If the pain gets worse go to the ED to get it removed.”

via Beyond the Clinical | Learning To Be A Better Physician Leader.

When you have a minute, go have a look, and bookmark it. Recommended.

Impeding progress

Dr. Edwin Leap (he of the excellently written and quite frequently updated EdwinLeap.com has started a second blog, to which he seeks submissions.

I think from the title of his new effort,  Impeding progress, you can get a feel for what he’s after.

Interesting idea, and while it’ll give all of a place to vent our spleens, I find blogs that are all negative rants to be cringeworthy after a while. I’m sure Dr. Leap (whom I met at ACEP this year, and he didn’t know me from Adam), will do a good editorial job.

So, go hither and submit your case of impeding progress!

Movin’ Meat: Medical Malpractice Self-Insurance — Is it right for your group?

ShadowFax is doing all EP’s a favor by explaining one of the more frustrating, and opaque areas of Emergency Medicine, group insurance. His group self-insures (apparently), and he knows way way too much about it:

One of the more painful elements of running a group practice is the ritual abasement before the god-like executives at the insurance company annual malpractice insurance re-bid. It’s kind of like a visit to the dentist: guaranteed to be uncomfortable and with the potential for a very unhappy surprise. Also, it leaves your face numb and drooling. The only thing that matches it in pain is writing the check every quarter, year after year, and then looking back at your actual, you know, losses, and seeing that you have paid for insurance way way more than you ever lost in liability claims. It’s got the all visceral satisfaction of lighting a pile of money on fire.

via Movin’ Meat: Medical Malpractice Self-Insurance — Is it right for your group?.

He’s got another, just as informative follow-on post, and the promise of at least one more. Frankly, it’s a primer for groups who are considering this (and AFIK, mine isn’t).

My anti-doc-muzzling rant was linked

This one.

By Dr. Helen (without a comment) and by Don Surber with a very nice comment. It’s astounding to me how commenters everywhere are on board with suppression of speech. And sad.

Nice to be noticed, though.

Aggravated DocSurg: Waiting & watching for Jon

We were invincible. Packed into Jon’s pale yellow Olds Cutlass, the car I’d always wanted, careening down the road between our high school and its “sister” all-girls school, we’d sing along with whatever was playing on the oversized speakers garishly mounted in the back. More exactly, we’d usually be screaming along with the music, which was loud enough to rouse more than a few nearby drivers from their afternoon daydreams.

We were on our way to……take a typing class.

via Aggravated DocSurg: Waiting & watching for Jon..

It goes sideways after that.

Excellent post.

Dr. Wes: The Wren

Dr. Wes: The Wren.

A beautifully done blog post. Recommended.