The Year in Review

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From the opioid epidemic to out-of-control EpiPen pricing, it has been an eventful year for emergency medicine. Let’s recap some of the important issues that caught our eye in 2016. 

WORDS MATTER
The words we use give powerful messages – so let’s get them right. Beginning last February we began writing about how “Reasonable Practice” represents what we do, and how we do it, better than the phrase “Standard of Care.” Our daily practice depends upon our patient population served, demographics, health system resources, treatment options, and patient expectations for care. Likewise, reducing “Practice Variation” is a more useful mantra than “Unnecessary Testing.” We try to use evidence-based medicine to homogenize our practice and limit variation, but EBM has benefits, risks, and unintended consequences. EBM is population-based, not individual-based. As emergency physicians, even though our practice is population-based, our focus is and will always be trying to provide the best care for each individual patient.

Yes, words matter and emergency medicine needs a better message. We know who we are, but journalists, the media, legislators, institutions, and health agencies still don’t have a clear idea of what we do and why EM is so important. When is the last time EM was credited for its role in the management of multiple major trauma in the US? I should say ‘when was the first time’? The media were silent about the role that EM played after the shootings in Orlando, Chareston and San Bernardino. Sometimes it can feel as though emergency physicians and EDs don’t even exist. And what about our perception in Hollywood? In the recent film Dr. Strange, Rachel McAdams plays an emergency physician. But Google her character and you’ll find her alternately described as “trauma surgeon,” an “emergency trauma doctor,” and a “real successful/highly skilled emergency room doctor.” She followed “a bunch of surgeons” to learn what to do. Now, if the newspapers and movies can’t get us right, it’s no wonder that the public is still mixed up about who we are.

PRESCRIPTION INJUSTICE
Epipen pricing leads the pack, and is the most glaring, but not the only example of a critical life-saving or life-maintaining drug that has been priced out of reach for many of our patients. In October we discussed how the Wal-Mart $4 list is no panacea and GoodRx.com doesn’t provide coupons for some of our best drugs. Emergency physicians have become experts in identifying  reasonable cost choices for our patients, yet Society guidelines (including ACEP guidelines) don’t even offer low cost choices for treatment for common conditions. ACEP, ACOEP, AAEM: why have you remained silent about “Prescription Injustice?”

QUALITY MEASURES
We reported in August that quality measures will impact reimbursement beginning in 2019, and will grow over several years in scale, complexity and consequences. We’ll need registries to collect EHR data by provider and to calculate the complex metrics needed for reporting.

MACRA consolidates the confusing alphabet soup of prior reporting requirements, which had been spread out among several agencies, each using different methods. MACRA and MIPS (Merit-Based Incentive Payment System) were written with registries like ACEP’s CEDR in mind. MIPS is divided across four domains – quality metrics, advancing care information, improving clinical practice, and resource utilization. Payment adjustment will become substantial, with both penalties and the potential for performance bonuses. Don’t like it? Get used to it.  Metric measurements may narrow the bell-shaped curve of practice variation, and may improve efficiencies of care. Whether it will also lower the cost of care remains to be seen.

MENTAL HEALTH AND PSYCHIATRIC BOARDING
Mental health and substance abuse problems have become double-edged swords for emergency medicine. Since last December we covered the insufficient numbers of inpatient beds, clinics, and mental health professionals, the rise in substance abuse in the US population, and inadequate reimbursement for care. Together these issues have contributed to the overwhelming increase of mental health patients in our EDs. Psychiatric telehealth can only minimally improve situations in our EDs. Why is it so hard to generate an effective response to mental health and substance abuse issues in our society today? Compare this to society’s response to deaths and injuries from motor vehicle crashes, which resulted in technical solutions that included trauma systems, seatbelts, airbags, and improved highways. Perhaps the solutions for mental health and substance abuse problems are just too difficult, tedious, or expensive to implement. Perhaps there are no technical, societal or biological solutions – certainly none that offer immediate results. However, as long as mental health patients must be accommodated for initial assessments and boarded for days in our EDs, hospital operations and state institutions will remain protected and have little motivation to work for change.

OPIOIDS
Don’t blame us for everything. Once the pain score became the 5th vital sign, emergency physicians and nurses learned to relieve pain aggressively. Now that the Pandora’s Box of opioids has opened, it will be hard to put the lid back on. In April, July and October we  covered how the over-use of opioids can lead to inadequate pain control for legitimate and painful conditions. And no matter how hard we try, some patients just won’t leave the ED without a prescription for short-term opioids. Patients who violate their pain contracts can be fired from their pain clinics, and the only place to go to satisfy cravings or signs of withdrawal is—the ED.

Let’s face it, there are insufficient resources or alternatives for pain control to meet the needs: alternative therapies like acupuncture, chiropractic treatment, application of ROC tape, massage, and physical therapy are limited resources and may not appeal to some patients and physicians. Ketamine in appropriate doses, topical or gel anesthetics, anti-inflammatories, and local anesthetic injections are alternatives for acute pain control that need to be added to our skill sets.

EM EDUCATION
EM residencies continue to thrive, and the market for residency-trained EM physicians remains limitless. In August we highlighted the ACOEP which is in the process of assimilating its US osteopathic EM residencies into the ACGME fold, and a large number of osteopathic programs are expected to be able to make the transition.

Four international EM programs have received ACME-I approval: Tan Tock Sing in Singapore; American University of Beirut in Lebanon; Sultan Qaboos University Hospital in Qatar, and the Oman Medical Specialty Board in Muscat, Oman.

All these developments portend a growing and strong clinical, political, and global voice for emergency medicine.

O HENRY MY HENRY
It’s with real regret that we report that Greg Henry will no longer be providing EPM with his monthly column which offered sage advice, pithy and incisive commentary, wit, wisdom, Latin quotes, literary theses and opinions on just about anything and everything. He does his best to keep ACEP in line. Greg has promised to continue providing an occasional column to EPM as issues arise, so you haven’t heard the last of him yet.

THANK YOU EDITORS AND WRITERS
EPM couldn’t thrive without the dedicated contributions of our writers. We aim for contemporary and timely reviews on clinical, administrative, and legal topics important to emergency physicians. There are many people on our masthead who make this magazine possible, but I would like to specifically thank our cast of section editors: Amy Levine, MD – Pediatrics; Dan Quan, MD – Toxicology; Ashley Bean, MD – Global EM; Teresa Wu, MD & Brady Pregerson, MD – Ultrasound; Michael Levy, MD – EMS; Jesse Pines, MD, MPH – Health Policy; Lauren Southerland, MD – Geriatrics; Chris Courtney, MD – Orthopedics; Joshua Broder, MD – Radiology

I would also like to specifically thank our contributing editors:  Alex Koyfman, MD; Christina Shenvi, MD & Jyoti Mahapatra, MD. And a special thanks to social media editor and Twitter moderator Seth Trueger.

ABOUT THE AUTHOR

EDITOR-IN-CHIEF
Dr. Tintinalli is currently a professor and Chair Emeritus of Emergency Medicine at the University of North Carolina. In addition to teaching in the emergency medicine department, she is an adjunct professor at the UNC Gillings School of Global Public, and a frequent lecturer in the School of Journalism and Mass Communication. Dr. Tintinalli is double boarded in emergency medicine and internal medicine. She was the founder and first president of the Council of Emergency Medicine Residency Directors. She is a former president of ABEM as well as the Association of Academic Chairs in Emergency Medicine. She is a past winner of ACEP's James Mills award as well as ACEP's National Education Award. And of course, she is the Editor-in-Chief of 7 editions of her eponymous textbook, which is arguably the best-known EM text in the world.

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