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.)

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

Well, let’s consider their actual track record:

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.



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.

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.
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.
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.

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.

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.

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.

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.

“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.”

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!


How I feel about ATLS, in someone else’ tweet


[Read more…]

How To Discourage a Doctor | The Health Care Blog

A modern parable.


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.

Scribes in 2014

I’ve written about scribes in the ED before (here’s one from 2007) and continue to utilize their services. Did I say utilize? Wrong thought: enjoy and marvel in their help is more my experience. I’m spurred to extoll their virtues and my experience after reading “Attack of the Scribes” by the great twitterer @SkepticScalpel  (he also blogs at SkepticalScalpel.blogspot.com ).

Read the article, it’s well written though more than a touch odd; why’s a doc who’s never worked with scribes editorializing on their pluses and minuses? The literature review is fair, and there probably isn’t enough scholarship on the issue of whether scribes can have a measurable impact on physician productivity. I think we’ve only scratched the surface with scribing in the hospital, as I think every nurse should have a scribe. Imagine, nurses nursing rather than staring at screens, checking boxes! It would be hugely liberating for them.

I’m going to insert some quotes from the article then answer them:

“The emergence of the electronic medical record (EMR) has spawned a new occupation—the scribe.”

No, scribes have been around since ink and paper, and maybe before. I would accept that the EMR has spawned a new medical occupation, though we used scribes in the paper chart world before the EMR. It is certainly true the EMR has facilitated the explosion of scribe utilization (and companies to fill that need).

“I have no personal experience with scribes, but I suspect their notes would tend to be too long rather than too short. Do we really need longer notes in charts? No. Residents need to learn how to write concise progress notes that do not duplicate what is already in the chart. This would require a culture shift by faculty and senior residents who tend to expect voluminous notes.”

Scribes document something like doctors without scribes: all over the map for volume. Some distill the history in a few sentences, some type verbatim, and there’s a mixture between. In the ED, as the note is pretty heavily templated, and so much fluff and junk are automatically stuck in there, an extra sentence or three isn’t contributing to note bloat. I would never scribe any other than a Senior resident, as learning what and how to document is part of the education.

Additionally, docs 40 and above didn’t grow up with keyboards like our scribes did; that means less information added by poor typists, which isn’t good for the patient or the documentation.

The presence of a third party during the doctor-patient interaction has not been an issue so far, but it is conceivable that some patients might feel uncomfortable.”

I’ve had one patient ask the scribe to leave the room. I introduce myself, introduce the scribe as ‘my assistant’, and it’s not an issue otherwise. (We do excuse them for the more intimate exams).

“When a scribe enters a note in an EMR, it must be cosigned by the physician. Experience with dictated H&Ps, notes, and operative reports shows that most of these entries are not carefully proofread before they are signed. Using scribes opens up new vistas for plaintiffs’ attorneys if patients experience bad outcomes.”

I disagree; the issue is the quality of the documentation, and it’s irrelevant who pushes the keys. The name at the bottom of the chart is responsible for the content. Before Texas’ Prop 12 several of us were sued, and the use of scribes never came up as a problem in depositions or trials.

True story. I know someone who had pain in her arms. The scribe documented the doctor as saying “consider a mass” instead of what he actually said, “consider MS.””

Professional transcriptionists get words wrong frequently, and the speech-to-text used by our radiologists is often inadvertently hysterical (‘Sono: Renal and Nasal’ was a recent report header), so communication errors happen. That’s why we read and edit charts.


I don’t need a study to tell me scribes make me more efficient, but we did one anyway. We were very efficient on paper charts, with scribes, and the EMR showed up. We went through the training, and had people time scribe-on-paper vs the EMR for time; the EMR was tremendously slower (40% more time required), which was a big hit in an efficient system. We’ve gotten better, but several of our docs use two scribes to get their speed back (and more; I now see more per hour than I did on paper). We didn’t publish our data. Maybe we should have.

Our scribe company* has gotten a whole lot bigger, and a lot more corporate for better and worse. They turn out trained and enthusiastic scribes, and they’re still wonderful to work with. I showed up very early for work the other day and decided to start early, which reinforced that I can manage the EMR and do my own documentation, and I’m terrifically glad I don’t have to.

Here’s Greg Henry (ACEP past President and EM lecturing fixture) being interviewed about scribes by Nick Genes (genius and blogger/twitterer):

ACEP 2012: Greg Henry v. Nick Genes Part 3 – Scribes from Logan Plaster on Vimeo.

Dr. Henry has  also been quoted (though I cannot find it) as saying ‘the ER doctor should be a free floating brain’, meaning let the doctor do the thinking they’re trained to do and let anything that not that be done by someone else. It makes zero sense for the highest compensated in the department to be the typist (not a slam on typists, it’s about the best use of time and talents).

Scribes. If you use an EMR, or don’t, get them. They’ll make you money, and they’ll make your day way, way better.

*Full disclosure: I independently contract with a CMG that supported and then spun off our scribe company. I’m also friends with the scribe company senior management, and they’re good folks. I’d say nice things about our scribes if none of that were true, but don’t want my relationship to be an issue.


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