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Each year at the annual Scientific Assembly of the American College of Emergency Physicians over 300 Council members convene to consider, debate, and vote on a slate of resolutions put forth from the membership through their various state chapters. Some are no more than housekeeping details. Others, however, are directives for ACEP regarding residency education, legislative actions, promotion of contractual language, or cooperation with other specialties and/or the AMA.  But many members of ACEP – even after years of membership – know little of these resolutions. And if you don’t know about the resolutions you can’t lobby your representatives to speak on your behalf. This year EPM executive editor Mark Plaster got a copy of the resolutions before the Scientific Assembly and asked one of the seasoned members of ACEP, Dr. Richard Stennes, former President of the College, for his comments.

The Major Resolutions:

#21– Alternative to Independent Payment Advisory Board

Request the AMA to advocate for an All Specialty Physician Board as an alternative to IPAB and advocate for an ASPB to advise or replace the IPAB.

Mark Plaster (MP): This is a big one. Apparently the 15 member Independent Payment Advisory Board (IPAB) established by health care reform might not even have an EP on the panel. That can’t be good.

Richard Stennes (RS): I don’t support the concept of the IPAB as it’s currently setup. Fifteen people are selected who are above the law to do things that will be done behind closed doors. I think that should be repealed an be substituted with what they’ve proposed here. There would be somebody from every specialty representing the broad spectrum of medicine. However, the politics of this is going to be nearly impossible. We can take this to the AMA. The AMA would probably be sympathetic and happy to run with it. But to get it through the legislature and overcome the Health Reform Act of Obama, not that we shouldn’t try, but it would be a very, very steep climb, difficult to do.

#22– Emergency Medicine and Transitions of Care

Participate in defining the role of emergency medicine in transitions of care, engage in discussions with various regulatory agencies regarding performance measure and proposed standards for emergency medicine transitions of care, monitor and provide input into reimbursement issues tied to transitions of care, including performance incentives and collaboration with accountable care organizations.

MP: The authors of this resolution are simply noting that since EPs are greatly impacted by various parties on issues related to admission standards, performance measures, and the like, we should be represented in the decision process. It resolves to have “engage all significant forums of discussion.” But does this resolution really do anything?

RS: This is another one that’s sort of complex but the healthcare reform has created more opportunity for participation. I opposed the AMA supporting Obama Care as did many other delegates did when we were in Houston. But the AMA endorsed it. Why? As Steve Stack and others pointed out, this thing was probably going to pass. If we weren’t supportive, then we’re not in the game. We won’t be there to help write the regulations by the 150,000 new regulators. That makes sense I suppose. Although I think in retrospect if they had opposed it three more representatives would have said no, and it wouldn’t have passed.

#23– EMTALA

Submit recommendations to CMS regarding uniform interpretation and fair application of EMTALA; work with CMS to institute confidential, peer-reviewed process for complaints; work with CMS and others to require that complaints be investigated consistently according to uniform standards and investigators required to adhere to appropriate professional conduct during investigations; report back to the 2012 Council.

MP: This makes sense to me. This is advocating for a standardized approach to investigating any alleged EMTALA violation. 

RS: During my presidency we thought this was an onerous regulation, but it was coming and we participated to try to change it to the way we could. It turned out to be a good thing, I think, for us. It is, however, complex. And one of the issues here is the authority of the people in charge of enforcing EMTALA. They seem to have unilateral discretion to come in, take over, and make hell for the hospital or the doctors by an individual sort of decision. That’s what this addresses. This has an enormous impact on a variety of people. There needs to be some way of getting a hearing and hopefully prevent some of the collateral damage that comes when a threat or an allegation is made through EMTALA.

#24– Emergency Medicine Action Fund

Requires that the ACEP Board of Directors maintain oversight of the “Action Fund” through written rules aligned with the Conflict of Interest policy and by votes requiring a simple majority.

MP: Wes Fields, whom I interviewed last month in EPM, says that the Action Fund is a coalition of coalitions. I questioned him about the possibility of some voices, possibly well funded ones, might be heard over others. Is this what that is about?

RS: I think it’s a trying to fix a problem that right now doesn’t exist. I would not be so much in favor of this. I don’t know the whole story. Wes Fields has worked hard on this. I think they’ve created a very effective way of influencing regulation and legislation. I don’t know that now is the time to tinker with it. ACEP has significant oversight and rules and conflict of interest statements and it’s very clear where ACEP is in terms of moving forward. 

#25– Regulate Marijuana Like Tobacco

Revises ACEP’s policy statement “Tobacco-Products - Public Policy Measures”

MP: It seems like I’ve heard ACEP discuss this before.

RS: Yes, this is seen in some fashion every year. But it hasn’t passed because ACEP can’t be seen by the public as supporting marijuana. This resolution, on the other hand, basically says “Well it’s smoke like tobacco smoke, so let’s regulate it like tobacco smoke.” And some tax issues are in there as well so I think this one has a better chance of passing than others have. And I would be generally supportive of it. 

#26– Single-Payer Universal Health Insurance

Support the adoption of single-payer health insurance and explore opportunities to partner with other organizations that favor the single-payer approach.

MP: Why are we still talking about this? Wasn’t this put to rest by the Affordable Care Act?

RS: This is our friend from Michigan who I’ve debated before at Scientific Assembly on this issue. He is a distinguished councilor. He has for years and this is still another go at it. I think some of the whereas’s are probably not true and wouldn’t do what it imposes to do. I don’t think that trying to get a single payer in the United States is a good idea personally. I’ve listened to members of the AMA stand up and say “well my gosh if we can get a single payer in our state and they paid like even Medicaid pays in my state, oh man, we would be in clover.” Well then the guy from California stands up and says “We’re going out of business because of 19% collection rates with Medicaid” 

If you go with a single payer it always gets racheted down, it’s never racheted up. And you bring everybody down to the lowest common denominator. I don’t think it’s good in a pluralistic society to have one payer making all the rules and the decisions. 

This has come very close to passage in the past because there are a number of doctors, many of whom are employed by hospitals and are not independent contractors. They’re not subject to billing. They’re what you might call “kept physicians.” Certainly east of the Mississippi most emergency physicians are employed. West of the Mississippi they’re independent contractors. 

Let’s pass this because it keeps coming back every year and I’m tired of hearing about it.

#27– Tax Relief for Uncompensated/Undercompensated Medical Care

Investigate federal tax relief for medical professionals that provide medical services to uninsured and underinsured patients.

MP: This sounds like a great idea, but it seems that it needs to be fleshed out a little more. Asking ACEP “investigate federal tax relief” is a big request. Does this have any chance of passage as it is currently stated?

RS: This comes up almost every year at ACEP. It comes up every year at the AMA. I think it’s a wonderful idea, but they know it has not a chance in hell of passing.  How much is it going to cost to run after this windmill? You’re going to have to pay staff to go research this stuff unless individual members were to do it. I think that the likelihood of passage is slim, particularly in today’s environment of wanting more tax revenue not less . The President wants to increases taxes on “the wealthy” which includes most doctors.

#28– Chapter Options for E-Marketing to ACEP Membership

Amend ACEP policy to allow electronic marketing of courses, products, or services from chapters to the entire ACEP membership.

MP: Chapters can get emails to send to their own chapters, but not to other state chapters. Changing this seems to make sense.

RS: I think the issue now as they defined in there is that it costs a lot for direct mail and the only way that the state chapters have access to the mailing list is through direct mail and it costs a lot of money.

#29– Due Process for Emergency Physicians

Review and revise current policy statement, “Emergency Physicians Contractual Relationships,” send to other organizations with a request that it be distributed to their membership, and provide to other entities deemed appropriate by the Board of Directors.

MP: The authors note that due process is an important right enjoyed by every other medical staff member, supported by the AMA and ACEP. Doesn’t it make sense to publicize the support for this process as widely as possible?

RS: This gets into some of the AAEM issues about life is unfair. But then no one ever said life is going to be fair. Emergency physicians are a little different than the typical member of a medical staff who admits patients to the hospital. Emergency physicians are the front door of the hospital. We’re like teachers who want to have tenure. It would not be right if a hospital who has a problem with an emergency physician who has a lousy personality with a lot of patient complaints, even if he or she is a good clinician, if they can’t get rid of them. 

I’ve had doctors like that. It was usually very early on, the first shift or two, the nursing director or whomever would call up and say “Where did this turkey come from?” Hey get rid of this one before they really started.

I can remember a case where a doctor did something visible to the members of the emergency department. The Department of Health wanted to talk to the guy. I said, “He isn’t here anymore.” They let it drop. But the doctor told me “I have due process rights.” But I told him that if he went to a judicial hearing he could lose his license. You have to be careful what you ask for in due process.

The informal method is very often the best way. Now certainly there are emergency physicians who are going to lose their jobs but it isn’t because of something that somebody else in the group typically did. It’s because of what they choose to do. Life is governed by the choices that you make. And when you make certain choices then other people are forced to make choices too. You may not like it but the ball starts typically in the doctor’s court.

#30– Emergency Physician Contracts & Medical Staff Activities/Membership

Develop model language for emergency physician employment contracts prohibiting termination related to involvement in performance improvement, patient safety, or other medical staff activities; that the model language specify due process; and that ACEP work with major employers of emergency physicians to provide that the model language is incorporated into emergency physician contracts.

MP: The authors note that many contracts state EPs should only be able to be terminated on grounds related to their professional competency or conduct. But this kind of model language would give them an out if they can claim that their behavior was related to patient safety or medical staff activities. Isn’t this just protection from being fired because some powerful staff member doesn’t like you?

RS: I think what this says is that if you’re a whistle blower on your medical staff or your emergency department or concerned about some issue that you can claim is related to performance improvement or patient safety, that basically you become a protected species. And nobody can get at you. If you’re going to come to a hospital with a contract that says everyone is protected for all this stuff, your chances of getting that contract is none compared to the next group that comes in with equally qualified guys who don’t have it in there. The hospital asks themselves “Do I want to buy this problem with a potential protected species, a whistleblower?” The hospital is simply going to say, “I know it’s good for patient safety and I appreciate your concern, but I don’t think we need that, so see ya later.”

#31– End-of-Life Care

Study how emergency medicine can positively affect end of life care addressing limited resources; work wtih other appropriate professional societies to present a unified front in addressing end of life care;) submit a resolution to the AMA House of Delegates regarding end of life care; and provide a report to the membership on ACEP’s efforts to address end of life care issues.

MP: In an ironic twist of language, this has become Greg Henry’s raison d’être. But I have to agree that it might just be the most important discussion in medicine today.

RS: This is probably the single most important and best resolution in here and one that we certainly can take to the AMA. We’ve already taken some of this kind of stuff to the AMA and people worried that we would set up death committees or deny people healthcare , you know, let granny die. The problem is how it’s labeled. If we we can implement something like this on a nationwide basis it would dramatically reduce the cost of healthcare and reduce the amount of human suffering.

Of course anything with Greg Henry’s name on it is going to get attention. I suspect that there is no downside as far as I can tell in this resolution. I think it’s a great resolution.

#32– Inappropriate Utilization of ACEP Credentials to Further Corporate Business Practices

Adopt a policy prohibiting members of the ACEP Board of Directors from profiting from their ACEP positions by using them for business purposes that are not related to furthering the business of the College.

MP: Is this really necessary?

RS: Impossible to enforce and I don’t think that you want to.

#33– Medication Shortages

Work with stakeholders to address medication shortages

MP: This strikes me as telling ACEP to move a mountain. Is ACEP in any position to effect the drug market?

RS: This resolution is attempting to effect a marketplace phenomenon. There is no point in tilting at that windmill.  We don’t have enough money. We can’t make it happen. We can’t make drug companies make more human immunizations. We can’t make them make more drugs. This is way outside of our ability to have an influence.

#34– Professional Liability Litigation Education in Residency

Work with EMRA and CORD to develop policy advocating for inclusion of the professional liability litigation process and coping mechanism in GME curricula; that the joint policy be submitted to emergency medicine residency directors for consideration; and that ACEP advocate for inclusion of the professional liability litigation process and coping mechanism education as it pertains to the overall practice of emergency medicine and wellness of emergency physicians.

MP: Learning how to cope with litigation as a part of residency? I barely had time to learn all the clinical skills that I needed to know. This is a good idea, but is it going to crowd out more important education goals?

RS: There ought to be more stuff on malpractice and risk minimization in residency training. 

#35– Professional Liability Litigation Support

Explore the development of a centralized, web-based clearinghouse of educational materials and resources on professional liability litigation stress; publicize the availability of the the same; work with chapters to lobby for legal protection of emotional support from physician peers and committee meetings, communications, and records regarding litigation support as confidential and not subject to subpoena; further develop a network of peer counselors; publicize the availability of the professional liability peer-to-peer counseling network.

MP: This seems like a good idea, but I’m not clear how big it is and how much responsibility ACEP has for this.

RS: It’s a nice concept but it would be a big job and I think the net effect, positive impact for all the effort, would be minimal for the cost and time involved. 

#36– Sexual Assault Training in Emergency Medicine Residency

Work with CORD to facilitate development of standard guidelines for emergency medicine resident education on performing sexual assault exams; work with CORD and other organizations to develop a training curriculum in sexual assault examination for adoption by all emergency residency programs and practicing emergency physicians.

MP: Sexual Assault Nurse Examiners handle all of that where I practice. 

RS: Should training occur so that you’re familiar with what’s involved? I think it’s absolutely essential and you need to be prepared to do it. But I think our advocacy needs to be the development of the SANE nurses.


Housekeeping

A lightning round of nuts and bolts resolutions 

#12– Board Officer Terms and Election Timing

Changes the terms of Board officer other than the president-elect, president, and immediate past president to correspond to the College fiscal year instead of the Scientific Assembly. Removes the stipulation of “at least one year remaining” to seek election for secretary-treasurer and vice president.

MP: The authors feel that ACEP is so important, so exhausting and, in some cases, is the only face to face meeting, that some of the officers needs to be named in June prior to ACEP.

RS: I don’t know that I share necessarily all their concerns about the electionary process. Part of my concern there is that if you are locked into the position as VP or Chair or ST in that fiscal year, and you would like to run for President-elect it appears that you are not going to be eligible. If that’s true I’m not so sure that that resolution fixes anything and it may make it worse.  

#13– Closing the Loopholes

Stipulates that Board of officers serving beyond their term as an elected director are ineligible for a new officer position, except the president-elect and the president, and limits the eligibility to seek election as the chair of the Board to directors still within their term as an elected director. Removes the ability of any director serving on the Board beyond their term as elected director to seek election for president-elect.

MP: Doesn’t this just prevent a director from extending his/her time on the board by running for President Elect?

RS: I don’t know that I agree with that one so much either. There is a lot of talent waiting to come up that wants to get into leadership roles. I don’t think that we ought to be shutting off the opportunity to run for President of the organization just because you run out of time on the Board. 

#14– Endorsement for Council Resolutions & Bylaws Amendments

Changes the requirements for submission of all Council resolutions to include sponsorship from the president or chairperson representing a component body of the Council, the national Board of Directors, or a committee of the College. Eliminates the ability for only two member to submit a resolution. Requires approval by the Steering Committee for submission of the late or emergency resolutions.

MP: Doesn’t this give the President or Council Chairperson a veto over a resolution BEFORE it is ever heard by the Council?

RS: We have 28,000 members out there who have creativity. It is not necessarily restricted to the elected leadership. Sometimes the elected leadership may not agree and it can’t rise to the top. 

#15– Filling of Vacancies in the Offices of President-Elect and President

Clarifies the process for filing a vacancy in the offices of president and president-elect.

MP: When a President can’t fullfill his/her office, should the next person simply fill the remaining term or start a new one?

RS: The rosolution wants to clarify that the President-elect will assume the office of President if the President can’t serve. 

#16– Vacancy in the Office of President or President-Elect

Revises the process for filling a vacancy in the offices of President and President-Elect.

MP: This is a competing resolution.

RS: 16 says basically the Vice President will succeed to the duties of the office but not necessarily be the President. I think that one is more in line with what a Vice President ought do and doesn’t sort of muck things up. 

#17– Society for Academic Emergency Medicine (SAEM) Councillor Allocation

Establishes that the SAEM will be allocated one councillor.

MP: This seems like a pretty obvious approval.

RS: Yes.

#18– Dissemination of Resolutions with Background Information

Amends the “Resolutions” section of the Council Standing Rules to codify that resolutions are not disseminated with background information.

MP: Why is this housekeeping detail needed?

RS: If the Steering Committee thinks it’s a good idea then I wouldn’t argue against it.  

#19– Distribution of Printed or Other Material During the Annual Meeting

Adds a new section to the Council Standing Rules requiring permission from the Speaker to distribute any materials to the Council during the annual meeting.

MP: Same question?

RS: I think that’s probably a good idea.

#20– Submission and Handling of Written Testimony

Stipulates that written testimony must be submitted at least 72 hours in advance of the Reference Committee hearing, cannot exceed 250 words, and if read cannot exceed the time limits set for in-person testimony.

MP: I got tired just reading the 498 pages report. I can imagine that everyone will support anything that streamlines these marathon meetings. 

RS: That’s another good one. 

 

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