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lifeline NOVEMBER 2017

Page 12

BURNED OUT? Just Say No & Teach Others Well

4 PRESIDENT’S MESSAGE

6 ADVOCACY UPDATE

12 GUEST ARTICLE

16 ANNOUNCEMENTS

17 UPCOMING MEETINGS & DEADLINES

18 CAREER OPPORTUNITIES

6

California ACEP Board of Directors & Lifeline Editors Roster2017-18 Board of DirectorsAimee Moulin, MD, FACEP, PresidentChi Perlroth, MD, FACEP, President-ElectVivian Reyes, MD, FACEP, Vice PresidentVikant Gulati, MD, FACEP, TreasurerSujal Mandavia, MD, FACEP, SecretaryLawrence Stock, MD, FACEP, Immediate Past PresidentReb Close, MD, FACEPJohn Coburn, MDCasey Dart, MDCarrieann Drenten, MDDoug Gibson, MD, FACEPKevin Jones, DOJohn Ludlow, MD, MBA, FACEPKaren Murrell, MD, MBA, FACEPLuke Palmisano, MD, MBA, FACEPMaria Raven, MD, MPH, FACEP Nicolas Sawyer, MDLori Winston, MD, FACEP

Advocacy FellowshipAimee Moulin, MD, FACEP, Director

Lifeline Medical EditorRichard Obler, MD, FACEP, Medical Editor

Lifeline Staff EditorsElena Lopez-Gusman, Executive DirectorKelsey McQuaid-Craig, MPA, Director of Policy and ProgramsLucia Romo, Membership and Education CoordinatorLauren Brown, Government Affairs AssociateMeri Thresher, Office Assistant

NOVEMBER 2017 Index of Advertisers

California ACEP – Member Renewal Page 14

California Hospitalists/ Emergency Physicians Medical Group, Inc Page 18

Emergency Groups’ Office Page 13

Emergency Medical Management Associates Page 13

Emergency Medical Specialists of Orange County Page 18

Emergency Medicine in Yosemite Page 15

Emergency Physicians Management Page 18

Independent Emergency Physicians Consortium Page 5

Ohio ACEP Emergency Medicine Board Review Courses Page 11

St. Jude Medical Center, Fullerton Page 18

Ventura Emergency Physicians Page 18

12


2 | LIFELINE a forum for emergency physicians in california

TABLE OF CONTENTS |

2017 LEGISLATIVE

REVIEW

Central Coast Emergency Physicians

Emergent Medical Associates

Emergency Medicine Specialists of Orange County

Front Line Emergency Care Specialists

Loma Linda Emergency Physicians

Napa Valley Emergency Medical Group

Newport Emergency Medical Group, Inc at Hoag Hospital

Pacific Emergency Providers, APC

Tri-City Emergency Medical Group

University of California, Irvine Medical Center Emergency Physicians

Jasjit Adlakha

Ashley Advincula

Yom Alemante

Samuel I. Decker

Drusia Dickson

Ghadeer Doman

Eric M. Frendt

Peter Hanna

Elisee Jionang Dapeu

Tamara Julius

Melanie Koppula

Igor Krivitskiy

Jonathan Bryan Lee, Medical Student

Eric Y. Leung

Justin Meyer

Brandon Perkovich

Eric S. Pittman, MD

Adam Sykes

Lily Vartanyan, Medical Student

Andrew Wynn

Lisa Yee

WELCOME new members!

100% GROUPS

NOVEMBER 2017 | 3

PRESIDENT’S MESSAGE |

By Aimee Moulin, MD, FACEP

Our Chapter has worked to improve systems of care for patients with

psychiatric illness. California ACEP has advocated for your ability to

make clinical decisions about patients with psychiatric illness so that

you can do what’s right for your patients. The Chapter has worked to

update the outdated LPS Act. We’re pushing to break down the barriers

to transferring mental health patients: supporting the creation of an

online psychiatric bed registry to help match patients to resources and

working to open up psychiatric facilities to patients will all types of

insurance.

So it was with much trepidation that we have followed the AnMed Health case that fined a South Carolina hospital under the Emergency Medical Treatment and Active Labor Act, otherwise known as EMTALA. EMTALA requires hospitals that accept Medicare to provide appropriate medical screening and treatment to stabilize the patient’s condition.

The mere whisper of an EMTALA violation strikes fear in every emergency physician and administrator. On top of that, add the frustration and legal mine–field of our antiquated laws governing involuntary treatment and this particular case has been especially fraught.

The struggle to find an inpatient bed at a designated psychiatric facility is something we all share. Decades of cuts to inpatient and outpatient services have taken their toll on our mental healthcare system. California has lost 25% of

inpatient psychiatric beds since 1995. As of 2016, California had 1 bed for every 5,886 people. 1 Nationally there has been a steady increase in emergency department (ED) visits by patients with mental health diagnosis; 10% of all ED visits are for psychiatric illness and almost 2% of all visits result in a transfer to an inpatient psychiatric hospital. 2, 3

The mismatch of the need for mental healthcare services and available resources places us, and our patients, in an impossible situation every day, every shift.

IMPOSSIBLE SITUATIONS


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The South Carolina based AnMed health system settled with the Office of Inspector General for $1.295 million for failing to appropriately screen and stabilize psychiatric patients presenting to their ED. The case involves 36 patients with serious mental illness, including suicide and homicidal ideations. These 36 patients, in the opinion of the treating emergency physician, needed inpatient psychiatric treatment at a facility equipped to treat patients on an in-voluntary basis. However, the state-run inpatient psychiatric facility designated to accept patients on an involuntary basis did not have enough beds to meet the demands of the community. Patients meeting criteria for involuntary hospitalization waited in the AnMed Health ED for an open bed. Sound familiar…?

A survey of California ED directors found patients were waiting in ED’s over 24 hours.4 Length of stay for psychiatric patients are significantly longer than for non-psychiatric patients with similar dispositions.5 Not surprisingly, closures of inpatient psychiatric beds have a measurable impact on nearby ED’s.6 It leads to an impossible situation that regularly plays out in EDs.

What is less familiar is that the AnMed Health System did have inpatient psychiatric services and an on-call psychiatrist. Yet the hospital didn’t make these resources available to help take care of their ED patients, even though patients in this case waited between six to thirty-eight days to be transferred. The EMTALA violation was for failing to use available hospital resources (i.e. psychiatry consultation) in the stabilization of psychiatric patients. AnMed Health did not admit liability under the settlement deal.

This case has raised a lot of questions. By citing the hospital for not obtaining psychiatric consults, some have argued this calls into question an emergency physician’s ability to medically screen and stabilize psychiatric patients. However, this case seems more to do with what obligations a hospital has to making its consultants available to emergency physicians who request them, rather than to suggest that an emergency physician is not qualified to medically screen and stabilized psychiatric patients. It also raises the question of what obligations a hospital has to provide consultation when they have telepsychiatry available.

Our broken mental healthcare system has placed emergency physicians in impossible situations. Clearly the status quo is not acceptable. We need solutions and resources to provide care for our patients will mental illness.

What do you think about the AnMed Health case? What solutions have you found to do your best to provide mental health care in the midst of a system that we all know if failing our patients and us? Post your thoughts on California ACEP’s social platform, ConnectED, by logging in at californiaacep.org. n

Thank you

REFERENCES

1. Lowe S. California's Acute Psychiatric Bed Loss. California Hosptial Association. 2017.

2. Capp R, Hardy R, Lindrooth R, Wiler J. National Trends in Emergency Department Visits by Adults With Mental Health Disorders. The Journal of emergency medicine. 2016;51(2):131-135.e131.

3. National Hospital Ambulatory Medical Care Survey: 2014 Emergency Department Sum-mary Tables, tables1,4,15,25,26. In: National Center for Heatlh Statistics DoHaHS, ed. Atlanta GA: Centers for Disease Control and Prvention; 2017.

4. Stone A, Rogers D, Kruckenberg S, Lieser A. Impact of the mental healthcare delivery sys-tem on california emergency departments. The western journal of emergency medicine. 2012;13(1):51-56.

5. Zhu JM, Singhal A, Hsia RY. Emergency Department Length-Of-Stay For Psychiatric Visits Was Significantly Longer Than For Nonpsychiatric Visits, 2002-11. Health affairs (Project Hope). 2016;35(9):1698-1706.

6. Nesper AC, Morris BA, Scher LM, Holmes JF. Effect of Decreasing County Men-tal Health Services on the Emergency Department. Annals of emergency medicine. 2016;67(4):525-530.

NOVEMBER 2017 | 5

ADVOCACY UPDATE |

Author Tim Madden

2017 was largely a successful year for the California ACEP advocacy team. We sponsored three bills, two of which were signed by the Governor.

One of the main policy areas we focused on was improving care for our mental health patients. After our tough battle with AB 1300 (Ridley-Thomas) in 2015-16, which attempted to make significant changes to the mental health laws in California, we took a step back and changed our approach. We met with numerous stakeholder groups to more closely listen to their view of the mental health system and explore places we could partner to make changes. This led to our introduction of AB 451 (Arambula) and AB 1119 (Limόn) which are detailed below.

California ACEP continues to make strides forward in deepening our relationships with key stakeholder groups to make improvements to the broken mental health care system.

Our focus going into 2018 will continue to be around mental health care but we will also be exploring other policy avenues to improve emergency care.

2017 LEGISLATIVE REVIEW


CALIFORNIA ACEP SPONSORED BILLSAB 40 (Santiago) – Governor Signed Bill

AB 40 would allow health information technologies to integrate with and automatically query the Controlled Substances Utilization Review and Evaluation System (CURES) on behalf of a registered provider. This means a summary of a patient’s opioid prescription history could be included directly in an electronic health record for you to access without having to take cumbersome step of separately logging in to manually check CURES.

AB 451 (Arambula) – Bill Held in Senate Appropriations

AB 451 would address two barriers to care emergency physicians encounter when trying to transfer patients with emergency psychiatric conditions:

• Emergency physicians report acute psychiatric hospitals routinely ask for the insurance status of a patient before determining if they will accept the transfer, despite the fact that this violates the spirit, if not the letter, of current law.

• A survey of emergency physicians in California revealed that, almost universally, hospitals require patients to be on a 5150 hold or they will not accept transfer of that patient from the ED. There is no such mandate in law.

AB 451 would improve patient access to emergency psychiatric transfers. This bill would require psychiatric hospitals which do not have an ED, to accept higher level psychiatric transfers, regardless of the patient's ability to pay, and states that hospitals may not require a patient to be on a 5150 hold as a condition of accepting a patient transfer. The bill is eligible to be heard again in 2018.

AB 1119 (Limon) – Governor Signed Bill

AB 1119 clarifies that providers do not need to obtain patient consent

to share mental health information for treatment purposes in an

emergency.

While both the Health Insurance Portability and Accountability Act

(HIPAA) and the even more protective California laws, the Lanterman

Petris Short (LPS) Act and the Confidentiality of Medical Information Act

(CMIA), allow providers to share patient information in an emergency

for treatment purposes, there is confusion on the part of many

providers who have interpreted the law to require patient consent.

This is a substantial barrier to effective care in the emergency

department where patients are in crisis and timely consent is not

always possible. Different interpretations mean some health records

are incomplete and others aren’t released to emergency physicians at

all. AB 1119 provides much-needed clarity.

Prop 56 Allocation for Increased Medi-Cal Payments

There was a significant battle between the Governor, the Legislature, and physician led stakeholder groups around how money raised through Proposition 56 (Tobacco Tax increase) should be used. The Governor, in his initial budget proposal in January, essentially stole the estimated $1.3 billion in expected Prop 56 revenue for benefit expansion under the Medi-Cal program, rather than increased provider payments as mandated by the initiative. The CMA threatened to sue the Governor for violating the language of Proposition 56, which eventually led to an agreement.

The agreement between CMA, the Governor, and the Legislature is to use $465 million for increasing primary care provider rates, of which $325 million would be for physician provider supplemental payments and $140 million for dental provider supplemental payments, for the current budget year. The Legislature agreed to keep in place $700 million of Prop 56 funds to be used for general Medi-Cal purposes as the Governor proposed.

There was also language that could result in to up to an additional $800 million in the 2018-19 budget year, if there are positive changes in the state’s fiscal condition. This language is rather vague and may not realistically lead to any increased supplemental payments.

Prop 56 Allocation for GME Funding

Prop 56 allocated $40 million to training new primary care and emergency physicians, yet the Governor’s budget directed these needed funds towards the general UC budget. There are currently only 17 emergency medicine residencies in California and more residency slots are needed to meet the workforce shortage.

The Legislature responded by directing the monies into the Song Brown program which can only be accessed by primary care residencies. We worked with residency directors to draft language that would allow emergency medicine residencies to qualify for these funds. Unfortunately, the final budget deal allocated $33 million of Proposition 56 monies to only primary care residencies through the Song Brown program.

CALIFORNIA ACEP SUPPORTED BILLSAB 6 (Lackey) – Bill held in Senate Rules Committee

AB 6 would require the Commissioner of the California Highway Patrol (CHP) to appoint a drugged driving taskforce to develop policies to

NOVEMBER 2017 | 7

address the issue of driving under the influence of drugs, including

prescription drugs. The language of the bill was included in a budget

trailer bill, which was signed into law.

AB 74 (Chiu) – Governor Signed Bill

AB 74 requires the Department of Housing and Community

Development to establish the Housing for a Healthy California Program,

which will award grants to help fund interim and long-term housing.

AB 175 (Chau) – Bill held in Senate Appropriations Committee

AB 175 would require manufacturers to submit the package or label of

a marijuana product to the Bureau of Marijuana Control for approval to

ensure it is childproof and is not attractive to children.

AB 210 (Santiago) – Governor Signed Bill

AB 210 authorizes counties to establish a multidisciplinary personnel

team that facilitates linkage of homeless adults, children, and families

to housing and supportive services.

AB 350 (Salas) – Governor Vetoed Bill

AB 350 would amend the Control, Regulate, and Tax Adult Use of

Marijuana Act (AUMA) to specify that a marijuana product is deemed

appealing to children if it is in a shape normally associated with candy,

such as an animal or fruit.

AB 501 (Ridley-Thomas) – Governor Signed Bill

AB 501 authorizes the State Department of Social Services to license a

short-term residential treatment center to operate as a children’s crisis

residential center.

AB 508 (Santiago) – Governor Signed Bill

AB 508 eliminates a licensing board’s ability to fine or deny licensure

of a health care practitioner if they are in default on a United States

Department of Health and Human Services education loan.

AB 583 (Wood) – Bill held in Assembly Appropriations Committee

AB 583 would extend the operation of the Emergency Medical Air

Transportation Act until 2030, providing funding to augment Medi-Cal

reimbursement rates.

AB 595 (Wood) – Bill held in Assembly Appropriations Committee

AB 595 would require any entity that intends to merge with or acquire a

health care service plan or health insurer to receive prior approval from

the respective regulator, the Department of Managed Health Care or

the Department of Insurance. Proposed mergers or acquisitions would

be required to meet certain criteria, including improved access to care

and not adversely affecting competition.

AB 727 (Nazarian) – Governor Signed Bill

AB 727 clarifies that counties may spend Mental Health Services Act

(MHSA) funds on housing assistance for children and adults who have

a serious mental illness.

AB 782 (Acosta) – Failed Assembly Revenue and Taxation Committee

AB 782 would create a state income tax deduction for the amounts

paid for health insurance and transportation costs associated with

seeking medical care.

AB 917 (Arambula) – Bill held in Assembly Appropriations Committee

AB 917 would require the Board of Governors of the California

Community Colleges and the Trustees of the California State University,

and encourages the Regents of the University of California, to adopt a

policy on student suicide prevention.

AB 989 (Cooper) – Held under submission

AB 989 would create a state income tax deduction for a contribution

made to a health savings account (HSA) in conformity with federal law.

AB 1136 (Eggman) – Bill held in Senate Health Committee

AB 1136 would require the State Department of Public Health to

solicit a grant under the 21st Century Cures Act to develop a real-

time, electronic database of beds in acute psychiatric facilities, crisis

stabilization units, residential community mental health facilities, and

residential substance use disorder treatment facilities.

AB 1140 (Obernolte) – Hearing cancelled by author

AB 1140 would create a state income tax deduction for a contribution

made to a health savings account (HSA) in conformity with federal law.


AB 1315 (Mullin) – Governor Signed BillAB 1315 establishes the Early Psychosis Detection and Intervention Fund, consisting of public and private funding, to expand access to evidence-based early psychosis detection and intervention services.

SB 189 (Bradford) – Governor Signed Bill

SB 189 creates specific waiver provisions for workers’ compensation coverage for professional corporations, worker-owned cooperatives, and closely-held family businesses. Last year, a bill inadvertently removed the ability for certain professional organizations, such as medical corporations, from waiving the requirement for physician to have workers’ compensation coverage. SB 189 corrects this problem.

SB 323 (Mitchell) – Governor Signed Bill

SB 323 authorizes a federally qualified health center (FQHC) or rural health clinic (RHC) to enroll as a Drug Medi-Cal certified provider, expanding access to alcohol and addiction treatment.

SB 374 (Newman) – Governor Signed Bill

SB 374 requires large group, individual, and small group health insurance policies to provide mental health and substance use disorder benefits in compliance with federal law. The bill would also authorize the Insurance Commissioner to issue guidance to health insurers regarding compliance.

SB 456 (Pan) – Bill held in Assembly Appropriations CommitteeSB 456 would allow federally qualified health centers (FQHC) and rural health clinics (RHC) to enter into an agreement with an entity to provide services that follow the patient.

SB 489 (Bradford) – Governor Signed Bill

SB 489 extends the timeline for hospitals and emergency physicians to bill for emergency medical treatment for injured workers from 30 days to 180 days. This bill was necessary due to a drafting error in a workers’ compensation reform bill from 2016.

SB 566 (McGuire) – Bill held in Senate Energy, Utilities and Communications Committee

SB 566 would require a telecommunications provider to notify the Office of Emergency Services (OES) via email whenever there is a 911 outage in a rural area. OES would be responsible for notifying

emergency services in the county affected by the outage.

SB 663 (Nielsen) – Governor Vetoed Bill

SB 663 would specify that a package or label of marijuana products is attractive to children if it has characteristics resembling a commercially sold candy, food, or beverage. Existing law already prohibits marketing marijuana products to children. This bill came forward after the state was slow in issuing regulations to provide guidance on what constituted marketing to children. Governor Brown vetoed the bill stating the regulations are being drafted and legislation is not needed.

SB 687 (Skinner) – Governor Vetoed Bill

SB 687 would extend the Attorney General’s review and oversight of nonprofit hospital transactions to include a nonprofit hospital’s attempts to eliminate or reduce emergency medical services.

SB 792 (Wilk) – Held in Assembly Local Government Committee

SB 792 would create the Measure B Oversight Commission and require the Commission to submit reports on Los Angeles County’s trauma network and Measure B Funds. Measure B was approved by Los Angeles County voters in 2002 and raises approximately $250 million annually to fund the County’s 14 trauma centers.

The bill was not heard in the Assembly but is eligible to be heard in January of 2018.

CALIFORNIA ACEP OPPOSED BILLSAB 334 (Cooper) – Held in Senate Public Safety Committee

AB 334 would authorize a health care provider to perform a sexual assault forensic medical examination if the alleged victim is unconscious or incapacitated. While we support efforts to increase access to sexual assault examinations that preserve time-sensitive evidence, we expressed concerns this bill did not include liability protections for the health care providers completing the exam when a victim cannot consent. We worked closely with the author and sponsor and were able to remove this language from the bill, changing the focus. With this amendment, we moved to a neutral position.

AB 820 (Gipson) – Held in Assembly Health Committee

AB 820 would establish a task force to develop a report evaluating community paramedics taking patients with mental health conditions to alternate destinations rather than the ED. Although the bill language only contemplated establishing a task force, the real goal of the bill

NOVEMBER 2017 | 9

was to expand the scope of practice of community paramedics to allow them to make determinations in the field as to whether a patient should go directly to psychiatric facility without going to the ED first. We attend numerous meetings with the author, sponsor, and Assembly Health Committee Members to convey our concerns that we need scientific, statistically validated data on best practices that maintain patient safety. The bill was never heard in the Assembly Health Committee. AB 820 is eligible to be heard in January 2018.

AB 859 (Eggman) – Governor Vetoed Bill

AB 859 would lower the standard of proof for elder abuse from “clear and convincing” to a “preponderance of evidence”. This bill would allow attorneys to circumvent California’s landmark Medical Injury Compensation Reform Act (MICRA). The Elder Abuse and Dependent Adult Civil Protection Act (EADACPA) has already been used by plaintiff attorneys to qualify for higher limits on attorney fees and damages for pain and suffering. Lowering the standard of proof for EADACPA cases will only increase attempts to circumvent MICRA.

The Governor vetoed the bill stating “intentional destruction or concealment of evidence, known as spoliation, is illegal… Accordingly, I don't believe changing the standard of proof is warranted.”

AB 1560 (Friedman) – Remains on Senate Floor

AB 1560 would have allowed physicians to supervise up to 18 of any combination of physician assistants, nurse practitioners, and certified nurse midwives. This dramatic expansion essentially rendered meaningless the supervision requirement, compromising patient safety. The bill stalled on the Senate Floor due to ongoing concerns with the change in supervision.

SB 419 (Portantino) – Failed in Senate Business and Professions Committee

SB 419 was initially introduced to prohibit prescribing oxycodone to persons under the age of 21. After significant opposition the bill was amended to require practitioners to educate patients on the dangers of certain pain medications when prescribing those medications to minors, as well as require the minor to see a pain management specialist before any subsequent pain medication is prescribed. We remained in opposition when the bill failed to pass the Senate Business and Professions Committee.

SB 746 (Portantino) – Never heard in Senate Education Committee

SB 746 would authorize a licensed doctor of chiropractic (DC), naturopathic doctor (ND), or nurse practitioner (NP) to perform a physical examination that is required for participation in an interscholastic athletic program.

SB 786 (Mendoza) – Never heard in Senate Health Committee SB 786 would require the Department of Health Care Services to deny an

application for a new alcoholism or drug abuse recovery or treatment

facility, if the proposed location would result in overconcentration of a

residential area. This measure only furthers the stigma of addiction at

a time when more addiction treatment services are needed. SB 786 is

eligible to be heard in January of 2018.

CALIFORNIA ACEP OPPOSE UNLESS AMENDED BILLS

AB 1250 (Jones-Sawyer) - Failed to Pass Senate

AB 1250 threatened the health care safety net by placing barriers on

contracting for physician services at county hospitals, by establishing

specific standards for the use of personal services contracts by

counties. Aimee Moulin, MD, President of California ACEP, spoke at a

press conference outlining the dangers of the bill. Despite failing to

pass out of the Senate, the bill is eligible to be heard in 2018.

AB 1650 (Maienschein) – Held in Assembly Appropriations Committee

AB 1650 would authorize the expansion of scope for community

paramedics to provide medical services, including post-discharge

follow up services for patients recently discharged from the hospital,

therapy for TB testing, hospice rapid response service, as well as case

management services and linkage to nonemergency services for

frequent EMS system users.

We met with the author and sponsor multiple times and requested

there be more structure placed into the bill including, but not limited to:

training, statewide protocols, and scope of program that more accurately

reflects the pilot programs currently evaluating the safety of these

practices. The bill was held in the Assembly Appropriations Committee.

SB 487 (Pan) – Never heard in senate Business and Professions Committee

SB 487 would prevent medical staff from imposing a maintenance

of certification requirement on physicians and surgeons in order to

maintain hospital or clinical privileges at a public hospital. The bill

would also limit hospital committee voting rights on issues impacting

patient care to physicians who spend 50% or more of their time

providing direct patient care.

Due to varied physician responsibilities, especially at academic centers,

we requested amendments to change the voting rights threshold to a

figure that was lower than 50%. The bill was never heard in committee

but is eligible to be heard in January of 2018. n


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As we have advanced the discourse externally about the collective pressures we face, we are simultaneously paving a path for students and residents who enter the workforce that will hopefully look different than the highly regulated and micromanaged medical world we currently practice in. But collective work is not enough. As individual attendings and seasoned physicians, we must mirror balance in our professional lives. To defend against burnout and physician abuse, we must teach our new physicians the art of saying no. Helping our new residency graduates and medical students recognize these abusive work environments, prioritize their happiness and values so that they can avoid pitfalls is

essential. In order to do so, we must recognize the role we as attending’ play in perpetuating physician abuse and burnout. We are part of the problem.

”You cannot teach what you do not know,” so the saying goes. As attending physicians, many of us are still learning how to say no. When we graduate residency many of us are straddled with considerable debt from student loans. We are used to working long hours that are out of our control. For a finite time, shorter for some trainees than others, we are beholden to hospital schedulers, program directors, and ACGME requirements. However, this period passes, even during the longest training process. Then, one is left with life after training.

This is the life we have worked hard for, made promises to our significant others and family that it would be better. However, if one does not prioritize the things that matter to you outside of medicine, create boundaries, by saying no to unreasonable requests, it will not be better. This is where the dream is deferred, and many of us find ourselves hopeless and disappointed. Mastering the art of no is important for physician well-being.

There are many of us out in practice, those who are seasoned, who have not yet figured out how to create professional boundaries for themselves. Our residents and students look to us for mentorship and leadership. We sit on hospital boards and committees but do not speak up. If we do not continually advocate for ourselves, they are left uncertain of their capability to do it. In my work with those in training, many are overwhelmed by the culture of negativity that surrounds us. While we continue to practice heroic measures in our fields, we are clinical innovators; we are academically astute, and the work-life balance perils in our personal lives are blatantly apparent. This generation of upcoming future physicians needs us to stand up and be accountable. While, as mentioned, there


Without question, the interconnectivity created by social media is a plus

when it comes to talking about physician burnout, suicide and policies

affecting our practice of medicine. We are no longer in independent silos

with the surgeons suffering in one corner and pediatricians elsewhere. Physicians

are no longer isolated contemplating if what they are experiencing is just unique to

them. We are developing collective voices. It is incredible to believe a profession that

requires some of the top academic performers and minds of any field is struggling

with basic concepts of control, equity and justice in the workplace — but we are.

Author Bande Virgil, MD

GUEST ARTICLE |


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are many collective improvements, on a daily basis we falter in the decisions for personal wellness that we fail to make. It is a disservice to our profession and those behind us.

Residents who work with physicians who have an antiquated perspective of extreme self-sacrifice become indoctrinated in a negative culture. The expression of professional success has long been sacrificing one’s well-being for patient care or medical service. We criticize our colleagues who recognize their need for rest, who prioritize special moments in the lives of their family members. We continue to make it difficult for mothers who are working, fathers who want to spend time with a newborn. These are physician culture issues as much as they are institutional problems. Therefore, it is imperative that we stop affirming this malignant perspective and say no. While those who choose to work in this manner make a decision to do so, others should not

feel bullied or pressured into a physician-led culture such as this.

There is nothing more troubling than watching a senior physician who has lost grip and control over the most precious commodity of their own time. Work does not define you unless that is your choice. We can all pursue excellence and be the best physicians we can for our patients but still take care of ourselves. It is a difficult balancing act but one that matters as much as completing

charts and attending CME. It is the great juggling task of our profession. The more we as attendings and seasoned physicians model this behavior, normalize balance and disavow the culture where physician personal needs are unimportant the easier it will be to transform the landscape of medicine from the external pressures we face. We must humanize the way in which we work as colleagues and physicians if not for our own benefit, then let’s do it for those behind us. n

This article was originally posted on KevinMD, FemInEM, and the Medelita blog.

Bande Virgil, MD is a board certified pediatrician with several years of practice in private settings and hospital-based medicine, as well as medical missions abroad. She is an assistant professor of clinical pediatrics and works with both residents and medical students. Dr. Virgil has a strong commitment to her family, married with two young children. She's also a writer and public speaker who is committed to normalizing the experiences of parenting, discussing the challenges, offering hope and solutions in her powerful words. You can read more of her work at her blog TheMommyDoc.com.

NOVEMBER 2017 | 13

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MEDICAL

EDUCATION

FOUNDATION

EMERGENCY MEDICINE IN YOSEMITE2 0 1 8

Wednesday, January 10th (Majestic Solarium – formerly Ahwahnee Solarium) • 8:30 AM Brunch: “Two Unique Journeys Through Emergency Medicine”

Richard Stennes, MD, Past President California Chapter, Past President ACEP, Board Member ABEM and so much more Jerry Hoffman, MA MD, Professor of Medicine Emeritus, UCLA School of Medicine, Anchor Member of the Rick and Jerry show (EMA) and Skeptic at Large

• 1:00 PM Ranger Guided Group Hike with Paul & Karen Amstutz: Mirror Lake (Meet in The Majestic Yosemite Hotel Lobby – formerly Ahwahnee Lobby • 5:30-6:30 PM Reception It’s A Party In Honor of Billy Mallon, MD

and a number of the Trailblazers of Emergency Medicine • 6:30 PM Dinner (Yosemite Lodge Cliff Falls Room) • 7:00-7:15 PM Welcome and Introductions: Ron Crowell, MD • 7:15-8:00 PM Ryan McGarry, MD: “The Making of ‘Code Black,’ the TV production” • 8:00-9:30 PM Musical Entertainment: TBD

2018 Emergency Medicine in Yosemite January 10 – 13, 2018

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Sponsored by Yosemite Medical Education Foundation (YMEF) Co-Sponsored by California ACEP

“This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint providership of the Center for Emergency Medical Education and Yosemite Medical Education Foundation.”

“The Center for Emergency Medical Education is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.”

The Center for Emergency Medical Education designates this live activity for a maximum of 14.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Approved by the American Osteopathic Association for 14.00 credits of AOA Category 2-A CME credit Physicians should claim only the credit commensurate with their extent of their participation in the activity.

Paul Auerbach, MD - Graham Billingham, MD - Marko Duic, MD - Dan Imler, MD - Dara Kass, MD - Angela Lumba-Brown, MD - James Manning, MD - Tsuyoshi Mitarai, MD

Nidal Moukaddam, MD - Arian Nachat, MD - Claritza Rios, MD - David Schriger, MD - Name Withheld - Ramin Tabatabai, MD - Christian Tomaszewski, MD - Veronica Tucci, MD

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YMEF CME FACULTY

Paul Auerbach, MD Graham Billingham, MD Dan Imler, MD Dara Kass, MD Angela Lumba-Brown, MD James Manning, MD Tsuyoshi Mitarai, MD

Nidal Moukaddam, MD Arian Nachat, MD Claritza Rios, MD David Schriger, MD Name Withheld Ramin Tabatabai, MD Christian Tomaszewski, MD Veronica Tucci, MD

YOSEMITE MEDICAL EDUCATION FOUNDATION FACULTY

Registration is open online atwww.yosemitemef.orgEarly Bird closes November 22, 2017

Join our 40th AnnualJoin our 40th Annual

NOVEMBER 2017 | 15

SAVE THE DATE

California ACEP’s Legislative Leadership Conference (LLC) Tuesday, April 17, 2018 | Sacramento, CA

CALIFORNIA ACEP CO-SPONSORED CONFERENCES

40th Annual Emergency Medicine in Yosemite January 10-13, 2018 Yosemite, CA http://www.yosemitemef.org/

Ohio ACEP Emergency Medicine Board Review Course February 1-5, 2018 San Diego Marriott La Jolla http://www.ohacep.org/aws/OACEP/pt/sp/cme_oralboard

The California Emergency Medicine Advocacy Fund (CEMAF) has transformed California ACEP’s advocacy efforts from primarily legislative to robust efforts in the legislative, regulatory, legal, and through the Emergency Medical Political Action Committee, political arenas. Few, if any, organization of our size can boast of an advocacy program like California ACEP’s; a program that has helped block Medi-Cal provider rate cuts, lock in $500 million for the Maddy EMS Fund over the next 10 years, and fight for ED overcrowding solutions! The efforts could not be sustained without the generous support from the groups listed below, some of whom have donated as much as $0.25 per chart to ensure that California ACEP can fight on your behalf. Thank you to our 2016-17 contributors (in alphabetical order):

• Alvarado Emergency Medical Associates• Antelope Valley Emergency Medical Associates• Beach Emergency Medical Associates• Berkeley Emergency Medical Group • Centinela Freeman Emergency Medical Associates• CEP America• Chino Emergency Medical Associates• Coastline Emergency Physicians Medical Group• Culver Emergency Medical Group• Eden Emergency Medical Group • Hollywood Presbyterian Emergency Medical Associates• Las Cruces Emergency Medical Associates• Los Alamos Emergency Medical Associates• Mills Peninsula Emergency Medical Group• Montclair Emergency Medical Associates• Napa Valley Emergency Medical Group• Orange County Emergency Medical Associates• Pacific Coast Emergency Medical Associates• Pacific Emergency Providers• Pacifica Emergency Medical Associates• Riverside Emergency Physicians• San Dimas Emergency Medical Associates• Sherman Oaks Emergency Medical Associates• South Coast Emergency Medical Group, Inc.• Tarzana Emergency Medical Associates• TeamHealth• Temecula Valley Emergency Physicians, Inc.• US Acute Care Solutions• Valley Emergency Medical Associates• Valley Presbyterian Emergency Medical Associates• VEP Healthcare, Inc.• Vikant Gulati, MD, FACEP• West Hills Emergency Medical Associates

CEMAF ANNOUNCEMENTS |


For more information on upcoming meetings, please e-mail us at [email protected]; unless otherwise noted, all meetings are held via conference call.

| CALIFORNIA ACEP UPCOMING MEETINGS & DEADLINES

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NOVEMBER 2017

7th at 9:00 AM Reimbursement CommitteeConference Call

10th Veterans DayChapter Office Closed

16th Board of Directors MeetingSacramento, CA

23rd-24th Thanksgiving HolidayChapter Office Closed

DECEMBER 2017

6th CHA Behavioral Health Conference

7th at 10 AM Government Affairs Committee (GAC)Conference Call

25th-January 1 Winter HolidaysChapter Office Closed

JANUARY 2018

3rd Legislature Reconvenes

9th at 9 AM Reimbursement CommitteeConference Call

12th Policy Deadline for Fiscal Bills

15th Martin Luther King, Jr DayChapter Office Closed

18th at 10 AM Government Affairs Committee (GAC)Conference Call

31st House of Origin Deadline

NOVEMBER 2017 | 17

To advertise with Lifeline and to take advantage of our circulation of over 3,000 readers, including Emergency Physicians, Groups, and Administrators throughout California who are eager to learn about what your business has to offer them, please contact us at [email protected] or give us a call at (916) 325-5455.

DOWNTOWN LOS ANGELES: Emergency Physician needed. $350,000 + incentive per year, malpractice paid, half days, half nights. ABEM ABOEM with experience. Present core group average 23 yrs tenure. 36,000 annual visits, paramedic receiving (no peds) STEMI Stroke, physician coverage 36-40 hrs/day, NP & PA coverage 12-20 hrs/dayFAX CV to 213 482 0577 or call 213 482 0588 or [email protected]

FULLERTON, CALIFORNIA: Join our ED team in beautiful north OC at St Jude Med Ctr. Our 36 bed state of the art ED serves >70K pts/yr with 54 hrs MD, 44 hrs PA and 100% scribe coverage per day, 9 hr shifts. We have held this stable contract for >36 years, have excellent back-up, 24hr in house Critical Care, OB, neonatologist and hospitalists. We are a STEMI receiving center, “Advanced Comprehensive Stroke Center” and provide excellent compensation with night differential. Partnership track available. EM BC/BE mandatory. Send CV to [email protected]

LOS ANGELES – CULVER CITY: Southern California Hospital at Culver CityRare opportunity to join a Westside LA ER group. Group seeks BC/BE emergency physician to work Part-Full Time as an independent contractor. Excellent compensation with malpractice paid. Nine hour shifts with 11 hours of PA double coverage. 90% nights shifts are covered by night doctors. A complete ED refurbishment has been completed with an ER rebuild and expansion in the future. Computerized Charting and PACS! Email CV and references to [email protected] Phone 951-898-0823.

RIVERSIDE, CA – PARKVIEW MEDICAL CENTER: Great opportunity to join a 15-year ER group. Group seeks BC/BE Emergency Physician to work Part/Full Time as an independent contractor. Excellent Top Tier Compensation based on productivity with malpractice paid. Ten hour shifts with MD double coverage and 12 Hour PA. Computerized equitable shift scheduling. Efficient Computerized Charting and PACS! A brand new ER expansion is under construction and it will quadruple the size of the ER.Email CV and references to [email protected] | Phone (951) 898-0823

SOUTHERN CALIFORNIA – ORANGE COUNTY: Full time and part time independent contracting emergency physicians needed for high volume, high acuity practices. Chest Pain Center, Stroke Center, Pediatric Level II trauma center - large independent group with forty years of clinical excellence for two acute care facilities. Expanding group needs BC/BE emergency physicians and pediatric emergency physicians. Excellent compensation, malpractice paid, scribes, midlevel providers, 8 – 9 hour shifts, excellent call panel coverage.Email CV and references to [email protected], fax to 714-543-8914

SOUTHERN CALIFORNIA OPPORTUNITIES:• Tustin, CA - Orange County - 73-bed community hospital, 8-bed ER,

paramedic receiving, low volume. 10 x 24hr = $240,000/yr + incentive

• East Los Angeles - 120-bed community hospital urgent care (non paramedic receiving) volume 700/mo. Guarantee $100/hr.

• Norwalk, CA - 60-bed hospital. 500-600 patient/mo. Paramedic receiving. $110/hr.

FAX CV to 213 482 0577 or call 213 482 0588 or email [email protected]

VENTURA CALIFORNIA: New hospital under construction and scheduled to open in the fall of 2017. Central coast of California and 70 miles from LAX. Positions available in two facilities for BC/BE emergency physician. STEMI Center, Stroke Center with on-call coverage of all specialties. Teaching facility with residents in Family Practice, Surgery, Orthopedics and Internal Medicine. Admitting hospital teams for Medicine and Pediatrics. Twenty-four hour OB coverage in house and a well established NICU. Physician’s shifts are 9 hrs and 12 hours of PA/NP coverage. All shifts and providers have scribe services 24/7. Affiliated hospital is a smaller rural facility 20 minutes from Ventura in Ojai. Malpractice and tail coverage is provided. New hires will work days, nights, weekends and weekdays. Send resume to Alex Kowblansky MD FACEP at [email protected]

CAREER OPPORTUNITIES |


Looking for an ITLS course?

EMREF offers the following California providers list:

Please call 916.325.5455 or E-mail Lucia Romo: [email protected] for more information.EMREF is a proud sponsor of California ITLS courses.

Search for upcoming courses: http://cms.itrauma.org/CourseSearch.aspx

American Medical Response (AMR)Ken Bradford, Operations841 Latour Court, Ste D, Napa, CA 94558-6259Phone: (707) 953-5795Email: [email protected]

EMS AcademyNancy Black, RN, Course Coordinator1170 Foster City Blvd #107, Foster City, CA 94404Phone: (866) 577-9197Fax: (650) 701-1968Email: [email protected]: www.caems-academy.com

Compliance TrainingJason Manning, EMS Course Coordinator3188 Verde Robles Drive, Camino, CA 95709Phone: (916) 429-5895 Fax: (916) 256-4301 Email: [email protected]

CSUS Prehospital Education ProgramDerek Parker, Program Director3000 State University Drive East, Napa Hall, Sacramento, CA 95819-6103Office: (916) 278-4846 Mobile: (916) 316-7388 Email: [email protected]: www.cce.csus.edu

ETS – Emergency Training ServicesMike Thomas, Course Coordinator3050 Paul Sweet Road, Santa Cruz, CA 95065Phone: (831) 476-8813 Toll-Free: (800) 700-8444 Fax: (831) 477-4914 Email: [email protected]: www.emergencytraining.com

Loma Linda University Medical Center tnatsissA evitartsinimdA ,senoJ enyL

Department of Emergency Medicine11234 Anderson St., A108, Loma Linda, CA 92354Phone: (909) 558-4344 x 0 Fax: (909) 558-0102 Email: [email protected]: www.llu.edu

Medic AmbulanceJames Pierson, EMT-P506 Couch Street, Vallejo, CA 94590-2408 Phone: (707) 644-1761 Fax: (707) 644-1784Email: [email protected]: www.medicambulance.net

Napa Valley CollegeGregory Rose, EMS Co-Director2277 Napa Highway, Napa CA 94558Phone: (707) 256-4596Email: [email protected] Web: www.winecountrycpr.com

NCTI – National College of Technical InstructionLena Rohrabaugh, Course Manager333 Sunrise Ave Suite 500, Roseville, CA 95661Phone: (916) 960-6284 x 105 Fax: (916) 960-6296Email: [email protected] Web: www.ncti-online.com

Oakland Fire DepartmentSheehan Gillis, EMT-P, EMS Coordinator 47 Clay Street, Oakland, CA 74607Phone: (510) 238-6957Fax: (510) 238-6959 Email: [email protected]: http://www.oaklandnet.com/fire/

Riggs Ambulance ServiceGreg Petersen, EMT-P, Clinical Care Coordinator100 Riggs Ave, Merced, CA 95340Phone: (209) 725-7010Fax: (209) 725-7044Email: [email protected]: www.riggsambulance.com

Rocklin Fire DepartmentChris Wade, Firefighter/Paramedic

Phone: (916) 625-5311Fax: (209) 725-7044Email: [email protected]: www.rocklin.ca.us

Rural Metro AmbulanceBrian Green, EMT-P1345 Vander Way, San Jose, CA 95112Phone: (408) 645-7345Fax: (408) 275-6744Email: [email protected]: www.rmetro.com

ytefaS cilbuP egelloC roinuJ asoR atnaSTraining CenterBryan Smith, EMT-P, Course Coordinator5743 Skylane Blvd, Windsor, CA 95492Phone: (707) 836-2907 Fax: (707) 836-2948Email: [email protected] Web: www.santarosa.edu

WestMed CollegeBrian Green, EMT-P5300 Stevens Creek Blvd., Suite 200, San Jose, CA 95129-1000Phone: (408) 977-0723 Email: [email protected] Web: www.westmedcollege.com

American Health Education, Inc

7300B Amador Plaza Road, Dublin, CA 94568Phone: (800) 483-3615Email: [email protected]: www.americanhealtheducation.com

Verihealth/Falck Northern California

2190 South McDowell Blvd, Petaluma, CA 94954Phone: (707) 766-2400Email: [email protected] Web: www.verihealth.com

Ken Bradford, Training Coordinator

3401 Crest Drive, Rocklin, CA 95765

Perry Hookey, EMT-P

PHI Air Medical, CaliforniaGraham Pierce, Course Coordinator 801 D Airport Way, Modesto, CA 95354Phone: (209) 550-0884 Fax: (209) 550-0885Email: [email protected] Web: http://www.phiairmedical.com/

lifelineCalifornia Chapter, American College of Emergency Physicians

1121 L Street, Suite 407Sacramento, CA 95814

PRSRT STDUS POSTAGE

PAIDCPS

The course physicians have trusted for 33 years!

Ohio ACEP in partnership with

in February 2018 in San Diego, CA!

www.ohacep.org | (614) 792-6506

Ohio ACEP Emergency Medicine Board Review Course

February 1 - 5, 2018

San Diego, California

Approved for AMA PRA Category 1 Credits TM.

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