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  • August 15, 2018 9:00 AM | Sally Winkelman (Administrator)

    WACEP President's Message, August 2018
    Lisa Maurer, MD

    I’m a partner in a medium-sized democratic group, big enough to generally be sheltered from huge swings in clinical load due to any individual's personal leave or hiring of a new partner.  I have EM doc friends who have mentioned that they’d have to miss out on previous commitments because of staffing changes such as those. That always felt like a far-away problem, until recently, when our group was fortunate to pick up another contract, significantly increasing the clinical load faster than any group could hire.  Bottom line: I got steam rolled, drowning in work and losing contact with my “real” life.  It was all voluntary by the way; in our group’s typical uber-democratic fashion, I was able to choose how many shifts I could bear for a handful of months until more docs were hired on.  Just now I’m coming out on the other side as a great new group of docs recently joined our ranks, and I’m able to look back and reflect on lessons learned during my own ebb and flow of clinical work that is common for emergency physicians. 

    Professional Lessons

    • The Good - I typically work a lesser load of clinical shifts than most partners in my group due to also taking on administrative work, but had more of a typical load as of late.  I felt all warmed up every time I was heading into the hospital!  The usual stale cobwebs and inertia after a few days off of clinical work was never there, making the first patient encounter of a shift just as smooth as the last.  Clinically I felt like a well-oiled machine and it makes me appreciate that there truly is a critical mass of patients that I personally must see on a regular basis to keep sharp.  This will likely prove useful to remember as I near retirement or consider other non-clinical opportunities.  Perhaps even now, clustering my shifts might be the way to go as I try to balance clinical and non-clinical duties. 
    • The Bad - I am typically an everlasting gobstopper of empathy.  I would never question the logic of a patient’s choice of ED visit versus a PCP office, or why 3 a.m. seemed like the right time to stop on in.  People have their reasons.  But just jack up my clinical load a bit (ok, a lot) and my shoulders started to tense with each bell of the ambo door.  I knew it was taking a toll on me when I would read the triage nurse’s note and immediately internally start to question the motives of the patient I was about to see.  An alarm bell went off in my head.  Although I realized one could argue that this type of questioning is totally appropriate, I knew it wasn’t my typical outlook, and it was an outlook that certainly made it harder for me to love my profession everyday.  Keeping my previous empathy might even be more important that having a warmed-up clinical mind, in my opinion.  It has quickly returned with my now decreased clinical load.
    • The Ugly - see below.

    Personal Lessons:

    • Prioritize priorities - I had it all set.  My google calendar was loaded up, defending my personal life from my shifts.  Workouts? Check.  Sleeping? Check check.  My kids were even getting scheduled so I would be sure to set aside time for them.  But man, something was lost in translation.  My husband and I were interacting more as the changing of the guards than anything else.  Google calendar doesn’t do well providing downtime and spontaneity.  Everything but the bare essentials went to the wayside.  I hadn’t hung out with my sister for months.  I stopped turning down invitations to meet up with friends because the invitations stopped coming after being turned down so regularly.  A friend even asked me what it was like to live and breathe work.  Eek!  That’s not what I signed up for.  We made it to the other side just fine and I’m having a great time catching up with everybody, but when there not enough slots to fit in all the priorities, something’s got to give.  I don’t think I’m alone among emergency physicians who aim to work to live, rather than live to work.  It’s easier than I thought to let it slip the other way. 
    • Guilt was gone - On the lighter side, the trouble I normally have with trying to balance work with everything else was suddenly easier when work ticked up, mostly because I got very skilled at saying no to protect my time.  Meeting mid-morning after a night shift?  No way, Jose.  PTA meeting on my night off?  Sorry, not sorry.  Cook dinner?  I’ve prepared some exquisite Subway for the family.  Outsourcing was in full force: yardwork, grocery shopping, scrubbing toilets? Buh-bye, buh-bye, buh-bye.  Even now that things have slowed down again, as long as I can swing it, I’ll attempt to keep the guilt away and the outsourcing full speed.  It’s amazing how the world continues to spin even though I haven’t personally balanced the school budget nor picked up a toilet brush.  Nothing like a little stress on my time management to help me flex those boundaries I should always set for myself. 

    For those of you in smaller shops with even smaller staffs, I imagine this swing in lifestyle is your reality.  Hats off to you.  You likely have many more lessons to share with the rest of us.  Share them!  Hopefully, my lessons could better prepare or at least normalize this sort of transition for a Wisconsin EM doc who will experience something similar soon.  Most importantly, it was worth it.  The docs in my group are my family, and even though I might have a few more tricks up my sleeve next time, I know I’m ultimately in the right place because I’d do it all again in a heartbeat for my group and profession that I am so lucky to have. 

    Editor's note: Send your own lessons-learned, stories from the front, and comments to Dr. Maurer by emailing WACEP@badgerbay.co.

  • August 14, 2018 11:55 AM | Sally Winkelman (Administrator)

    Bobby Redwood, MD, Immediate Past President

    Each year the Wisconsin ACEP board of directors, in conjunction with our membership, chooses three strategic priorities: one for our profession, one for our physicians, and one for our patients. These priorities are assigned to a task force, which is in turn given the institutional resources needed to effect real change.

    In 2018, WACEP is focused on reducing the ED length of stay for patients in acute psychiatric crisis (aka psychiatric boarding). To achieve this admittedly lofty goal, the WACEP psychiatric task force joined forces with the Wisconsin Medical Society and the Wisconsin Psychiatric Association with the shared goal of reducing ED length of stay for one of our most vulnerable patient populations. Our group meets once every six weeks, strategically laying the groundwork to revolutionize the way we operationalize the medical clearance and transfer of psychiatric patients in Wisconsin EDs. Thus far, the work group has recognized some of the most common bottlenecks in the medical clearance process, including unnecessary testing, requiring lab results prior to initiating the transfer discussion, lack of bed availability, lack of bed coordination, and various suboptimal transportation procedures. As of our last meeting, we are happy to report that we have reached a phase where feedback from our emergency physician workforce is needed.

    Our task force has honed in on the medical clearance process and the (unofficial) requirement that all patients have labs drawn as one of the most egregious bottlenecks in our broken system. Of psychiatric clearance and transfer. In collaboration with our psychiatry colleagues, the work group has identified the SMART medical clearance protocol as a potential solution to this bottleneck.

    The protocol, developed and tested in the Sacramento area, consists of a series of questions under the acronym SMART. A score of ‘0’ on the form indicates no further workup is necessary, and would allow for prompt transfer of patients from the ED to a more appropriate inpatient setting. In Sacramento, the SMART protocol has been successful in speeding up the transfer process for ED psychiatric patients, reducing costly and unnecessary diagnostic tests, and ensuring that patients receive timely treatment.

    Moving forward, our work group aims to draft a consensus white paper on best practices in the medical clearance of psychiatric patients in acute crisis, publish a recommended medical clearance protocol, and then begin the real leg work of implementing reforms in our state’s medical clearance process. We’d like to hear from you: What do you think of the SMART protocol? What are its strengths? What portions of the protocol will have to be modified for Wisconsin? What aspects of the protocol might not operationalize well in your ED and why?

    Email your responses to WACEP@badgerbay.co and help us decrease ED length of stay for Wisconsinites suffering from acute psychiatric crisis.

    Robert Redwood MD, MPH, FACEP
    Immediate Past WACEP President

    Sources:

    "The SMART Medical Clearance Protocol As A Standardized Clearance Protocol For Psychiatric Patients In the Emergency Department." Chi J. Nwaobiora. International Journal of Current Research, Vol. 9, Issue, 09, pp.57140-57147, September, 2017.

    "Stop the Madness: A Smarter Way of Medical Clearance". Aimee Moulin, M.D., Sierra Sacramento Valley Medical Society Medicine, November/December 2017.

  • August 13, 2018 12:18 PM | Sally Winkelman (Administrator)

    In order to address the issue of physician suicide, the Council of Emergency Medicine Residency Directors (CORD), in collaboration with AAEM, ACEP, ACOEP, EMRA, RSA, RSO and SAEM have come together to annually dedicate the 3rd Monday in September as National Physician Suicide Awareness (NPSA) Day, #NPSADay.

    Physician suicide is a tremendous issue in healthcare today.  While estimates of the actual number of physician suicides vary, literature has shown that the relative risk for suicide being 2.27 times greater among women and 1.41 times higher among men versus the general population. Each physician suicide is a devastating loss affecting everyone - family, friends, colleagues and up to 1 million patients per year.  It is both a very personal loss and a public health crisis.  Vision Zero calls on individuals, residency programs, health care organizations and national groups to make a commitment to break down stigma, increase, open the conversation, decrease the fear of consequences, reach out to colleagues, recognize warning signs and learn to approach our colleagues who may be at risk.  Let us challenge each other as individual, community, institutional and organizational to make changes to reach zero physician suicides. 

    Suicide can be prevented.  Be the one to be there. Shed light on this issue and change the culture of medicine to save lives. Learn more and receive updates and information as it is released.

  • August 13, 2018 8:54 AM | Sally Winkelman (Administrator)

    UW Madison will host a day-long workshop on Suicide Bereavement Clinician Training, presented by national experts Drs. Jack Jordan and Nina Gutin, on Wednesday, September 19, 2018 at the Pyle Center in Madison.

    This unique opportunity in the arena of suicide post-vention and prevention coincides closely with the conclusion of National Suicide Prevention Week. Few clinicians have been properly trained to understand and respond to the complicated features of grief associated with suicide loss. The workshop is designed to prepare clinicians for working with individuals who are grieving the loss of someone to suicide. 

  • July 18, 2018 12:29 PM | Sally Winkelman (Administrator)

    Ben Ho, MD
    WACEP Board Member

    For many of us summer in Wisconsin means time spent outside, whether on a trail, by the lake, in our yards, or if we are lucky, somewhere on a tropical vacation.  As we enjoy the activities that we love, however, we knowingly expose ourselves to a number of seasonal environmental factors: heat, UV light, and of course, ticks and mosquitoes.  We may know these arthropods best as nuisances that crash our barbecues and hitchhike on our trail walks.  As vectors for important communicable diseases, however, their significance goes much beyond this.

    Earlier this spring, the Department of Health and Human Services and the Center for Disease Control published a review of vectorborne pathogen transmission in Morbidity and Mortality Weekly Report.  Using data from the National Notifiable Disease Surveillance System, the authors reported on trends in both tick- and mosquito-borne illnesses from 2004, the first year that arboviral illnesses became notifiable, to 2016, within the United States and its Territories.  The report not only indicates a global increase in the incidence of vectorborne illnesses throughout the United States, but also identifies unique patterns of transmission at the local level.  Two general patterns are evident.  Tickborne illness reports rose steadily, doubling over the 13-year study period, and their greatest impact was on the eastern half of the country.  While Lyme disease accounted for more than 82% of tickborne illness reports, other diseases such as anaplasmosis, ehrlichiosis, Rocky Mountain Spotted Fever, and babesiosis also increased in identification.  The occurrence of mosquito-borne illnesses, on the other hand, was punctuated by epidemics, and was much more geographically dispersed.  While endemic outbreaks of Zika, Dengue, and chikungunya were limited to the Territories, local transmission in the Southeast was likely due to infected travelers returning home from these areas.

    A number of messages can be taken from this report.  Although Lyme disease might be the illness that we consider most commonly in Wisconsin, the world of vectorborne diseases includes many more pathogens.  In fact, if the next twelve years is anything like the last, we should expect increasing incidences of all kinds of different tick- and mosquito-borne illnesses.  The epidemiology of these diseases is unique, largely because transmission depends heavily on environmental factors such as the geographical range of their hosts, the feeding cycles of their vectors, temperature, and rainfall patterns.  Regions that were once too cold for ticks may eventually see Lyme disease; mosquito-borne illnesses once limited to tropical climates may creep further into the continental U.S., encouraged by heat waves, deforestation, flooding patterns, and human travel.  It already appears that the physical range of A. aegypti is increasing, setting the scene for outbreaks of dengue, Zika, and chikungunya in years to come.  To make matters worse, there are not many vaccines available to protect us (Rosenberg et al., 2018).  As the world around us changes, so will the diseases that we see and treat.

    Despite these challenges, there are several things that we can do as physicians and health advocates to address the growing threat of vectorborne illnesses.  As with everything in medicine, awareness of these diseases and having appropriate clinical suspicion based on history and physical exam will not only aid in diagnosis and treatment of our patients, but also improve reporting of disease transmission.  We can also reinforce common-sense strategies to limit transmission of these diseases to our patients: wearing long-sleeves and pants in tick and mosquito habitat, avoiding exposure during mosquito feeding times, keeping outdoor spaces clear of leaf litter and standing water, performing frequent tick checks on fellow humans and pets, and protecting ourselves with Deet and permethrin.  The world may indeed be changing, but our process of limiting risks and exposures to vectors have not.

    As a final point – have you ever wondered how effective the combination of Deet and permethrin is in deterring mosquito bites?  A study done in the 1980’s by the U.S. Air Force compared mosquito bite rates on control subjects wearing no protection verses subjects treated with 35% Deet and/or permethrin at a remote test site in Alaska.  Subjects using both 35% Deet and permethrin-treated clothing experienced only one mosquito bite per hour; subjects using no protection experienced on average 1,188 mosquito bites per hour, with a maximum rate reported at 3,360 bites per hour (Lillie et al., 1988).  There are two clear take-aways from this study: 35% Deet combined with permethrin offer excellent protection against mosquitoes, and never volunteer as a research subject for the Air Force.

    References:

    Rosenberg R, Lindsey NP, Fischer M, Gregory CJ, Hinckley AF, Mead PS, Paz-Bailey G, Waterman SH, Drexler NA, Kersh GJ, Hooks H, Partridge SK, Visser SN, Beard CB, Petersen LR. 2018. Vital signs: trends in reported vectorborne disease cases – United States and Territories, 2004-2016. MMWR-Morbid Mortal W. 67(17): 496-501.

    Lillie TH, Schreck CE, Rahe AJ.  1988.  Effectiveness of personal protection against mosquitoes in Alaska.  J Med Entomol. 25(6): 475-478.

  • July 17, 2018 12:17 PM | Sally Winkelman (Administrator)

    ACEP’s Quality Division is hosting a webinar “Hear from the Authorities: CMS moving from Volume to Value. The near and long term future of MACRA policy and MIPS scoring.” on Jul 25, 2018 at 1:00 PM CDT. 

    Register: https://attendee.gotowebinar.com/register/2256949217905190401

    After registering, you will receive a confirmation email containing information about joining the webinar.

  • July 16, 2018 10:32 AM | Sally Winkelman (Administrator)

    July 12, Wisconsin Health News

    Workers’ compensation premiums for businesses are set to decline by 6.03 percent this October, according to a statement from the Department of Workforce Development.  

    That could result in an estimated $134 million in annual savings for businesses, the Tuesday statement noted. It’s the third year that workers’ compensation rates have declined, following an 8.46 percent decrease last year and a 3.19 percent decline in 2016. 

    “A safe workplace results in a more productive and profitable one for employers,” Ted Nickel, insurance commissioner, said in a statement. "Employers are recognizing the relation between their employees' safety and the savings that ensue as premiums continue to decline." 

    Mark Grapentine, senior vice president of government relations for the Wisconsin Medical Society, said the report shows that “good news keeps coming” for the state’s workers’ compensation program. 

    “We’re already a national model, with faster return to work, fantastic patient satisfaction and ready access to the highest-quality healthcare in the nation – all at a cost per claim that is below the national average,” he wrote in an email. “Another significant insurance rate reduction is just more evidence that Wisconsin’s system is win-win for both businesses and their employees.” 

    Grapentine added that there’s room for improvement, pointing to a need for the state’s on-the-job injury rate drop below the national average. He added that healthcare providers are “always striving to find better ways to improve care.” 

    Chris Reader, director of health and human resources policy, also lauded the announcement. He said the reduction follows a national trend as employers and workers have invested in and focused on safety. But he noted that costs for medical treatment for workplace injuries are on the rise. 

    “Had Wisconsin enacted a medical fee schedule like almost every other state, medical costs also would have been kept in check and the insurance reduction today would have been even greater," he wrote in an email. 

    Reader also argued that the rate reduction doesn’t mean much to fully-insured employers who don’t pay insurance costs and are left footing “incredibly high medical bills.” 

    Proposals to establish a fee schedule haven't gained traction with lawmakers.

  • July 16, 2018 10:31 AM | Sally Winkelman (Administrator)

    The annual Wisconsin Health News CEO Roundtable is August 14 in Madison. A panel of the state’s leading health system and hospital leaders will discuss the most pressing issues facing their industry. Panelists include: 

    • Dr. Sue Turney, CEO, Marshfield Clinic Health System 
    • Robert Van Meeteren, CEO, Reedsburg Area Medical Center 
    • Dr. Alan Kaplan, CEO, UW Health 

    Register now (link).

  • June 27, 2018 12:09 PM | Sally Winkelman (Administrator)

    The Wisconsin Supreme Court issued its ruling today in the Ascaris Mayo v. Wisconsin Injured Patients and Families Compensation Fund case to uphold the $750,000 cap on noneconomic damages, thus restoring medical malpractice caps in Wisconsin.

    In January, a coalition of medical specialty organizations jointly filed an amicus brief with the Supreme Court in support of the cap. The collaborative efforts of Wisconsin’s medical community resulted in a major victory for physicians and helped preserve access to healthcare across Wisconsin.

    An amicus brief was filed on behalf of the Wisconsin Chapter of the American College of Emergency Physicians, the Wisconsin Academy of Family Physicians, the Wisconsin Academy of Ophthalmology, the Wisconsin Orthopaedic Society, the Wisconsin Psychiatric Association, the Wisconsin Radiological Society, the Wisconsin Society of Anesthesiologists, and the Wisconsin Society of Plastic Surgeons by Guy DuBeau and Axley Brynelson, LLP.

    The case centers around Ascaris Mayo, who lost her limbs after a Milwaukee emergency room failed to identify an untreated infection. A court awarded her economic damages as well as $15 million intended to compensate for pain and suffering.

    The state’s Injured Patients and Families Compensation Fund, which covers large medical malpractice claims in the state, moved to reduce the $15 million to $750,000. An appeals court backed the award and ruled the law unconstitutional.

    Chief Justice Patience Roggensack wrote the majority opinion upholding the law, in part because she said the Legislature acted rationally when creating the law.

    “We conclude that the Legislature's comprehensive plan that guarantees payment while controlling liability for medical malpractice through the use of insurance, contributions to the fund and a cap on noneconomic damages has a rational basis,” she wrote. “Therefore, it is not facially unconstitutional.”

  • June 20, 2018 1:27 PM | Sally Winkelman (Administrator)

    Join the Wisconsin Society of Addiction Medicine on Saturday, September 29, 2018 in Madison for a high-impact workshop day designed to provide education on high quality, evidence-based practices.

    The case-based learning format is designed for front line clinicians and trainees who have faced and will face the challenge of helping patients with substance use disorders. Clinicians who will benefit include nurse practitioners, physician assistants, primary care providers, emergency room providers, and other sub-specialists. Two morning and one afternoon options are available, including:

    • The ASAM Treatment of Opioid Disorder Course: Focus on Buprenorphine
    • Naltrexone in Treatment for Alcohol and Opioid Use Disorders: Case Studies and Practical Applications
    • Buprenorphine 2.0: I Have My X-DEA, So Now What? Case Studies and Practical Applications

    Learn more and register.

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