The Rape of Emergency Medicine, 2017 version

Summa Health, an Ohio Hospital system, recently changed ED contracts from their 40 year group to a new one. On FOUR DAYS’ NOTICE! Four days, over the Christmas/New Year’s Holiday. That sounds distinctly unsafe, beyond the gross lack of sense, or commitment to a 40 year partner.

In case you think this is going smoothly, here’s a post to the ACEP ED Informatics Section from one of their former doctors (reproduced here with permission in its entirety):

I wanted to inform you, my colleagues, about what is going on at my home institution.   You all know me as a colleague and a fierce advocate of patient safety in EHRs. I have published on EHR patient safety for ACEP task forces and I am heading up a new ACEP task force on EHR patient safety issue reporting. It is with sadness that I have to tell you what is going in right now at my home institution.  

Summa has gone to paper.  

About 36 hours ago, our contract was taken over by US Acute Care Solutions (USACS) formerly EMP, through a scandalous process, but they literally created no plan for EHR transition.  I was the director of informatics and I, along with the rest of the physicians, was notified 4 days before New Years Eve that we were out.  We were told that when the ball dropped, our contract was over.  The physicians coming in to take over were to arrive at the facility for the first time 1 hr before their shifts and we were to sign out to doctors that had no EHR access.  No access to old records, CPOE, PACS, etc.  They went the first 30 hours without access.  Nurses were asked to do triage protocols and put the orders in under the new medical director, the only one with an account.  This morning at 30 hrs into the process some were to start training.   Now, the only information I get now is hearsay.  We strongly believe the EMP/USACS has no chance of safely staffing our 5 EDs with a total of 175k volume using part-time docs who have other full time jobs.  Our 55 docs and 20 PAs are sitting at home right now, scared for the patients that show up at the hospitals where their group spent the last 4 decades saving lives.  As a board certified clinical informaticist, I offered my services up until midnight when our contract ended but they elected to move another direction.  To the patients of Summa, I’m sorry.

Anatomy of a takeover.

As all of you are emergency physicians, I thought you’d be interested in how something like this might happen.  It is sort of a tangent to the EHR story, but I’ll include it because it is so interesting.  I’ve attached various references and additional information about the ongoing issue.  In short, the wife of Dom Bagnoli (USACS/EMP’s CEO) is the individual our hospital assigned to work out the contract renewal.  USACS/EMP has long been our chief rival in the area, so this is an obvious conflict of interest. Summa has an ethics policy that against even perceived conflicts, so two of our ED physician executive recused themselves from the process although she did not.  EMP had former Summa contracts, but had poor quality, staffing issues, and bad EMS relationships and lost their contracts or sold them to other staffing companies.  The hospital system drug its feet on negotiations until the last minute.  Contract negotiations failed when Summa (the health system) wanted SEA (Summa Emergency associates-our physician group) to fund the residency core faculty hours and wanted us to continue staffing under-performing stand-alone ERs that were built in inappropriate markets.  We found out later that they had already been talking to EMP.  

EMP is offering $100k signon bonuses, and we have heard they are paying temporary doctors up to $1000 per hour during the first 2 week transition.  I do ask you as a colleague not to take advantage of this opportunity–it may benefit you this week, but it hurts us all in the long run.  

The hospital house staff council has voted no confidence against the CEO.  The EM residency director has pulled the EM residents from the ED to keep them from having to work with non-vetted, non-EM, and non-Board certified physicians.  He does not believe that it is safe for them and they should not be subject the undue service requirements of a hospital CEO’s bad decisions.  

We are hopeful that EMP/USACS will not be able to run the residency and the department, and that negotiation will resume to restore a safe emergency care in Akron.  

Sincerely,

{Redacted}

Newspaper Sources:

http://www.ohio.com/news/local/resident-physicians-at-summa-health-vote-no-confidence-in-system-president-1.737494

http://www.ohio.com/lifestyle/health/fire-chiefs-concerned-about-summa-health-system-emergency-room-plans-1.737312

http://www.ohio.com/news/break-news/summa-health-bringing-in-new-doctor-group-to-staff-its-ers-starting-new-year-s-day-1.737043

http://www.ohio.com/business/emergency-in-the-er-come-jan-1-it-s-unclear-which-doctors-will-be-staffing-summa-s-emergency-rooms-1.736916

While I have no dog in this fight individually, all ED docs need to be aware that this isn’t just happening in the Bad Old Days, it happened this year.

I feel worst for the 55 former physicians and 20 PA’s of the Summa ED’s who were so disrespected by Summa, and fellow Emergency Physicians. It will make it very hard for them to trust in their new employment, wherever that may be. I hope they don’t take the money bait and help bail these new contract holders out.

For those who aren’t familiar with the title of this post, here’s a link to the original book The Rape of Emergency Medicine as a free .pdf.

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:
http://www.hotcoffeethemovie.com/default.asp?pg=mandatory_arbitration

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

2016-09-01_15-53-49

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

Yes, the VA is without doubt the model for American healthcare

Well, let’s consider their actual track record:

Shot:
The Pentagon reported Friday that 265 active-duty service members killed themselves last year, continuing a trend of unusually high suicide rates that have plagued the U.S. military for at least seven years.
http://www.usatoday.com/story/news/nation/2016/04/01/us-military-suicides-remain-stubbornly-high/82518278/

 

Chaser:

A VA suicide hotline designed to help distressed vets, at times instead sent their calls to a voicemail message, provided no immediate assistance, and did not even return some calls, according to a new report. … The crisis center was recently the focus of a HBO documentary praising the workers’ tireless efforts to help vets. The film, “Crisis Hotline: Veterans Press 1,” even won an Oscar last year.
http://www.cnn.com/2016/02/18/us/va-crisis-line-report/

A former Marine intelligence officer told the Senate Veterans’ Affairs Committee on Wednesday he waited more than a year for care, and when he finally saw a VA psychiatrist, he was prescribed a medication for depression. When he reacted poorly to the prescription, however, he was not able to make a follow-up appointment for another two months.
http://www.militarytimes.com/story/military/benefits/veterans/2015/10/28/report-vets-still-face-long-waits-mental-health-treatment/74734474/
Two former Minneapolis VA employees … say they were instructed to falsify records to make it look as if veterans were canceling or delaying appointments, a practice they allege allowed VA managers to hide long appointment delays. … Investigators have said efforts to cover up or hide delays were systemic throughout the agency’s network of nearly 1,000 hospitals and clinics.
When Anthony McCann opened a thick manila envelope from the Department of Veterans Affairs last year, he expected to find his own medical records inside. Instead, he found over 250 pages of deeply revealing personal information on another veteran’s mental health.
http://www.npr.org/sections/health-shots/2015/12/30/461400692/patient-privacy-isn-t-safeguarded-at-veterans-medical-facilities
One complaint against an employee found they accessed a veteran’s medical records—in violation of the Health Insurance Portability and Accountability Act—61 times. The employee even posted the private medical information on her Facebook page and “discussed it with her friends.” … The only punishment this employee received was a two-week suspension.
http://observer.com/2016/01/this-couldnt-have-been-a-more-scandalous-week-for-the-veterans-affairs-department/

Katherine Mitchell, a VA doctor in Phoenix, said that shortly after she complained to the Veterans Affairs inspector general about safety concerns, the department punished her, citing patient privacy.https://www.washingtonpost.com/politics/federal_government/va-uses-patient-privacy-to-go-after-whistleblowers-critics-say/2014/07/17/bafa7a02-0dcb-11e4-b8e5-d0de80767fc2_story.html

The Department of Veterans Affairs has not listened to whistleblowers or protected them, and it also has not punished employees who tried to stop or interfere with whistleblowers, according to a letter the U.S. Office of Special Counsel sent to the White House and Congress on Thursday.
http://www.cnn.com/2015/09/17/us/veterans-affairs-whistleblower-osc-findings/

Last May, a three-judge panel of the United States Court of Appeals for the Ninth Circuit accused the department of “unchecked incompetence” and ordered it to overhaul the way it provides mental health care and disability benefits.
http://www.nytimes.com/2012/03/25/us/recent-california-suicides-highlight-failures-of-veterans-support-system.html?_r=1

A study by a VA researcher found that veterans with PTSD were nearly twice as likely to be prescribed opioids as those without mental-health problems. They were more likely to get multiple opioid painkillers and to get the highest doses.
http://www.wsj.com/articles/SB10001424052702304672404579181840055583388

We gathered data from five of the states with the most veterans. We found they are dying of accidental narcotic overdoses at a 33 percent higher rate than non-veterans.
http://www.cbsnews.com/news/veterans-dying-from-overmedication/

“Veterans are now required to see a prescriber every 30 days, but at the El Paso VA, they are unable to get an appointment, so they go without, or they do something they shouldn’t — they buy them on the street.”

“The VA let them get wound up on all these drugs and now they cut them off completely. … These guys are coming into my office and they are a goddamn mess and the VA is just blowing them off.”
http://www.startribune.com/cut-off-veterans-struggle-to-live-with-va-s-new-painkiller-policy/311225761/

HT: Tig (thanks, brother).

ZDogg sings about stroke

It’s good!

Follow him on twitter, @ZDoggMD or at this blog ZDoggMD.com

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.

 

When healthcare is literally legislated

Hint: it’s not good. A terrific article from Weingart and Faust.


If the drafted CMS measure goes into effect, we are hosed. Because data will be collected retrospectively, hundreds of patients will be deemed severe sepsis who were never actually sick.

Government organizations do not invent this stuff. Behind every measure there is, somewhere, a group of physicians that made it happen. Just as medical malpractice would not exist without plaintiff witnesses, these measures would not exist without us. Let’s fight back before it is too late.

Hint: it’s too late. Enjoy the people who wrote the tax code legislating your care.

 

Nursing Homes are restarting the ‘don’t send the MAR’ game

For a primer, from 2007, here.

Another patient, another absent MAR (if you don’t know that acronym, you didn’t read the lead in article!). Usually they send when we call, but not recently. Here’s an amalgamation of some cases:

Calls are made by the nurses at my behest. The MAR Will Not be Sent.

Per nursing, whom I work with daily and trust implicitly, here are the objections proffered:

1) It’s illegal to send our signatures
Really? No, it’s not.

2) It’s our policy not to send MAR’s
Good luck with that policy. It’s going to get you in trouble.

3) You don’t need that.
As it’s a patient who has a) gotten meds from you and b) that timing is a question and c) we don’t know what the timing is, yeah, we and the patient you sent to us need that.

4) We sent you a med list
Yes, you did. That’s a List of Meds, but we don’t know what’s scheduled, PRN, given, held, parameters, etc. That’s a dodge.

Allow me to quote me:

This is outrageous. A chronically ill patient is sent to a higher level of care for an acute problem, and without a complete information base; but not just that, information crucial to the care of the patient that’s being intentionally withheld.

It is a situation that makes me, frankly, nuts. When did intentionally withholding critical patient care information become acceptable? Seriously, have these people not learned from history? The coverup is always, always worse than the crime, and is looked upon less favorably and punished more severely that any original offense. You could ask Nixon, but he’s dead.

Send me all the info you have, and our patient will live or die based on their problem(s); withhold information I need, and it’s on you, Nursing Home nurses.

– See more at: http://gruntdoc.com/2007/06/nursing-home-mars-sent-to-the-ed-with-all-times-removed-a-new-and-horrible-trend.html#sthash.k1mXnxiK.W4zJDG1c.dpuf

And if you’re from the Texas NH Regulatory agency that emailed me after the first posting, please recontact. I’m ready to send you some facility names going forward.

America’s Emergency Physicians

Really good video!

VP Biden’s best speech

Joe Biden isn’t my cuppa tea.

Yet, his talk to TAPPS is the best contemporaneous speech by a Pol to military families who lost family members in combat. I now like him much more.

The NYT, Maureen Dowd, and Dr. Caplan

Behold, a very worthy rant.  Recommended.

A wonderful Fisking

I’m neither terribly for nor against paramedics working as employees in the ED, but I love people ripping apart straw man arguments.

Texas ENA’s Unprofessional Attack on EMS

Author’s note: I generally avoid posting non-tech matters on my blog, but this unprofessional, unsubstantiated, fear-mongering attack of EMS in Texas has me boiling. I present to you something that doesn’t just affect Texas EMS, but EMS in the entirety of the United States of America. This has been fought in other states, and if it isn’t stopped now, will set a precedent and spill into many more states and regions. If you want to advance, you don’t do it by holding your siblings down in mediocrity and attacking their skills and intelligence. They seem to have taken a page out of the book, “How to Get Ahead in Life by Attacking Your Colleagues.” It is uncalled for.

Go, now, and enjoy.

 

They call me ‘Doc’

For the mighty Navy Corpsmen, past, current and future.

 

What doesn’t kill you makes you stronger

unless it’s the tail rotor. They will straight up kill you.

Buy the t-shirt!

2015-02-09_23-23-32

How I feel about ATLS, in someone else’ tweet

Perfect.

[Read more…]

How To Discourage a Doctor | The Health Care Blog

A modern parable.

RICHARD GUNDERMAN, MD

Not accustomed to visiting hospital executive suites, I took my seat in the waiting room somewhat warily.

Seated across from me was a handsome man in a well-tailored three-piece suit, whose thoroughly professional appearance made me – in my rumpled white coat, sheaves of dog-eared paper bulging from both pockets – feel out of place.

Within a minute, an administrative secretary came out and escorted him into one of the offices. Exhausted from a long call shift and lulled by the quiet, I started to doze off. Soon roused by the sound of my own snoring, I started and looked about.

That was when I spotted the document on an adjacent chair. Its title immediately caught my eye: “How to Discourage a Doctor.”

via How To Discourage a Doctor | The Health Care Blog.