ACEP NowACEP Now https://www.acepnow.com Fri, 21 Sep 2018 16:18:33 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.8 Support EM Research: Join the Emergency Medicine Practice Research Network https://www.acepnow.com/article/support-em-research-join-the-emergency-medicine-practice-research-network/ https://www.acepnow.com/article/support-em-research-join-the-emergency-medicine-practice-research-network/#respond Wed, 19 Sep 2018 16:45:47 +0000 https://www.acepnow.com/?post_type=article&p=19771 The Emergency Medicine Practice Research Network (EMPRN) is the first emergency care practice-based research network developed by...

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The Emergency Medicine Practice Research Network (EMPRN) is the first emergency care practice-based research network developed by emergency physicians for emergency physicians. Survey questions are posed to 800 physician members (73 percent male, 28 percent female) and can come from researchers, clinicians, ACEP committees, federal agencies, foundations, and industry. To date, a total of 16 EMPRN surveys have been conducted with average response rates ranging from 25 to 50 percent. As shown in the following figures, participating physicians reflect the diversity of practice and culture within our specialty.

Geographical Distribution

Not only are EMPRN surveys a source of presentation and publication worthy data (see Table 1), they also provide a critical mechanism to gather timely information on emergency physician perspectives related to topics including medicolegal participation, stress relief habits, and natural disaster preparedness. As the only existing resource to provide such insight, EMPRN provides clear value to the emergency medicine community, as well as those interested in better understanding the acute care landscape.

Table 1: EMPRN Publications to Date

Title Author(s) Year Publication
EMPRN Surveys Emergency Physicians on Treatment of Deep Vein Thrombosis Schneider S. 2017 ACEP Now
Survey of Emergency Physician Approaches to Management of Asymptomatic Hypertension Brody A, Twiner M, Kumar V, et al. 2017 The Journal of Clinical Hypertension
National Survey of Emergency Physicians Concerning Home-Based Care Options as Alternatives to Emergency Department–Based Hospital Admissions Stuck AR, Crowley C, Killeen J, et al. 2017 The Journal of Emergency Medicine
National Survey of Emergency Physicians Concerning Home-Based Care Options as Alternatives to Emergency Department–Based Hospital Admissions Stuck AR, Crowley C, Killeen J, et al. 2016 The Annals of Emergency Medicine
Barriers to Emergency Physician Diagnosis and Treatment of Uncontrolled Chronic Hypertension Brody AM, Sharma VK, Singh A, et al. 2016 The American Journal of Emergency Medicine

Do you have five minutes to help our specialty? If so, please consider becoming a member of EMPRN. Becoming a member is simple—just go to the EMPRN site and click the “Join” link. Signing up is easy, and it will provide ACEP with essential information for our advocacy in Washington, D.C., and improving emergency care. To stay a member, just agree that you will complete three or four surveys a year, each of which will take just a few minutes of your time. Your colleagues and patients will be grateful for your efforts!

For information on submitting a survey to EMPRN, please contact Sam Shahid at sshahid@acep.org.

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2018 ACEP Elections Preview: Meet the President-Elect Candidates https://www.acepnow.com/article/2018-acep-elections-preview-meet-the-president-elect-candidates/ https://www.acepnow.com/article/2018-acep-elections-preview-meet-the-president-elect-candidates/#respond Wed, 19 Sep 2018 14:58:01 +0000 https://www.acepnow.com/?post_type=article&p=19615 Each year, ACEP’s Council elects new leaders for the College at its meeting. The Council, which represents...

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Each year, ACEP’s Council elects new leaders for the College at its meeting. The Council, which represents all 53 chapters, 39 sections of membership, the Association of Academic Chairs of Emergency Medicine, the Council of Emergency Medicine Residency Directors, the Emergency Medicine Residents’ Association, and the Society for Academic Emergency Medicine, will elect the College’s President-Elect and four members to the ACEP Board of Directors when it meets in September. This month, we’ll meet the President-Elect candidates.

Jon Mark Hirshon, MD, PhD, MPH, FACEP

JON MARK HIRSHON, MD, PHD, MPH, FACEPCurrent Professional Positions: professor, department of emergency medicine and department of epidemiology and public health, University of Maryland School of Medicine, Baltimore; senior vice-chair of the University of Maryland, Baltimore Institutional Review Board

Internships and Residency: emergency medicine residency, Johns Hopkins Hospital, Johns Hopkins University, Baltimore; preventive medicine residency, Johns Hopkins Bloomberg School of Public Health

Medical Degree: MD, University of Southern California School of Medicine, Los Angeles (1990)

Response

The other night, during a busy shift, a mid-60s woman came into my ED via ambulance with hypotension and inferior changes concerning for a ST-elevation MI on the EMS-transmitted ECG. Upon arrival, we confirmed the ECG changes and activated the catheter lab, and shortly thereafter, the patient went upstairs for catheterization and stenting. The system worked—a life was saved! Unfortunately, our dysfunctional, fragmented U.S. healthcare system is under siege and threatened from many directions, both internally and externally. While the system worked today for my patient, will it work tomorrow for your patient or family member with a life-threatening emergency?

Assuring appropriate financial and societal support remains a critical external threat to EM. Longtime emergency physician Paul Seward recently penned an article on Stat News describing EDs as “the ‘chewing gum and duct tape’ holding together U.S. healthcare.” As the cost of healthcare in the U.S. has skyrocketed, EDs are viewed as the healthcare safety net—or as stated by a previous U.S. president: “I mean, people have access to healthcare in America,” he said. “After all, you just go to an ER.” Out-of-pocket medical expenses are mounting astronomically while insurance companies are making record profits. Many Americans are only one medical emergency away from poverty or homelessness. We, as frontline providers, see this on a daily basis. Our EDs may be our neighbors’ front door to the hospital, but it is our window to the problems seen in our communities.

ACEP must, and I will, continue to fight to assure high-quality emergency care for all Americans. This is a multipronged approach, including legal, educational, and lobbying activities on both federal and state levels. Last summer, while having lunch with my senator, Ben Cardin, the federal champion of the prudent layperson standard, he was shocked to learn that prudent layperson was under siege again. ACEP and the Medical Association of Georgia are suing Anthem BlueCross BlueShield of Georgia for their policy allowing for retrospective denial for some care delivered in EDs. Previously, we sued the U.S. Department of Health and Human Services to require transparency of data and fair insurance coverage for emergency patients who are “out of network” because of a medical emergency. Our lobbying and educational efforts include almost daily interactions with policymakers and regulators, including high-quality, effective presentations at the RVS Update Committee, to assure that we are paid for the work that we do. We must, and I will, fight to make sure that we receive fair compensation for the care we deliver through supporting legal action, developing coalitions and partnerships, and testifying in front of politicians and the public.

“ACEP must, and I will, continue to fight to assure high-quality emergency care for all Americans. This is a multipronged approach, including legal, educational, and lobbying activities on both federal and state levels.” —Jon Mark Hirshon, MD, PhD, FACEP

However, assuring fair compensation is only one external threat we face. The ever-increasing regulatory burden remains a significant problem, negatively impacting our productivity and our well-being. We face this concretely on a daily basis with the growing burden of documentation as enforced by our electronic medical records. For every five minutes I spend with a patient, I spend 15 to 20 minutes documenting. This negatively impacts my rapport with patients, coworkers, and trainees. Reducing administrative burdens is critical and was a central theme of my testimony earlier this year before the House Committee on Ways and Means’ Health Subcommittee on reducing administrative burdens for physicians in the Medicare program. Decreasing regulatory burdens and improving our work environment are critical aspects of improved care delivery and emergency physician well-being. This will be a critical objective of my time as ACEP President.

Internally, we are faced with the challenge of unifying the multiple voices in EM into a strong and effective chorus. We are a diverse group and bring many different perspectives together in order to care for our varied patients. Companies with greater diversity have been shown to be more successful from a business perspective. ACEP will be more successful through embracing diversity, and not just gender and race diversity but the many aspects of our practices—gender, race, ethnicity, large groups, small groups, academics, rural providers, young physicians, individuals near retirement, etc. Together, we can agree on specific topics and issues and work together collaboratively on these. This will strengthen our voice. On other topics, we can continue to disagree respectfully and professionally without personal attacks. Speaking with one voice will allow us to be heard above the discordant clamor found in Washington, D.C., and in many state capitols.

Emergency physicians are caring, thoughtful professionals. We work hard, and we play hard. We care about our patients and for our colleagues. ACEP and EM play a critical and ever-increasing role within the healthcare system. I will work together with our many partners to forcefully advocate for EM and to sustain and to grow the support for our important work. Working together, we can and will make a difference.


William Jaquis, MD, FACEP

WILLIAM JAQUIS, MD, FACEPCurrent Professional Positions: senior vice president, Alliance Operating Unit–Envision, East Florida Division; attending physician, Aventura Hospital, Aventura, Florida

Internships and Residency: emergency medicine residency, Case Western–Mt. Sinai Hospital, Cleveland

Medical Degree: MD, Medical College of Ohio, Toledo (1989)

Response

Externally, the biggest threat is our current form of funding and paying for healthcare. The “system” is far from a coordinated entity but more a collection of stakeholders with their own interests exceeding the needs of the system as a whole. Those who fund and pay for the care are often deeply separated from the consumers of care, and the complicated approach to payments leaves us all confused. Consumers should have more transparency about what the cost to them for their care will be, but we are unable to give it to them because we have no idea across our delivery system how we will be paid, if at all. We have insurers who have hidden lists for which they will retrospectively deny payment, and every day it seems there is a new story or “study” that highlights “excessive” ED costs. In this setting, it is incredibly difficult to provide timely care for patients, help them understand the costs of that care to them, and appropriately staff and reimburse our providers. EM is unique in this battle from our EMTALA mandate to see all patients regardless of ability (or intent) to pay. Addressing this issue will take all of us acting in many different venues. For our patients, we need to continue to advocate for access by requiring essential health services to be covered and paid according to prudent layperson laws. This also has and may continue to require legal action such as the current suit (July) against Anthem. We have some solutions that are improvements to the issue of fair coverage, and that message needs to continue through coalitions, the courts, social media, and public relations.

“We have insurers who have hidden lists for which they will retrospectively deny payment, and every day it seems there is a new story or ‘study’ that highlights ‘excessive’ ED costs. In this setting, it is incredibly difficult to provide timely care for patients, help them understand the costs of that care to them, and appropriately staff and reimburse our providers.” —William Jaquis, MD, FACEP

Internally, our biggest threat is our inability in many situations to find a shared vision as a physician community. As the phrase goes, we have met the enemy and he is us. I cannot determine how many meetings I have attended where the physicians spent a great deal of time arguing with each other while the non-physician team stands by, leading to no directed action. Through many means in society as a whole, we are becoming more polarized rather than recognizing what is shared in the middle. This is true of EM at times as well. Do not misunderstand: I highly value the discourse of opposing views, as they often lead me and us to a better understanding of an issue. We must, however, make sure that, in doing so, we do so with respect, and we understand there must be a forward direction. We can do so by continuing the dialogue on our important issues with civility, keeping our criticisms more private, and moving forward publicly with a shared vision and praise.

We are well positioned to address the threats and the opportunities to EM. The leadership of the College—both physician and ACEP staff—is strong and well-informed. The working relationships with Committees and Sections and Task Forces are constructive, utilizing the immense talent we have within the College. The Council leadership and the members of the Council have consistently shown their dedication to defining the important work we do. Our leaders have influence not only in the College but within their groups, within other specialty societies, and with leaders in the health systems. At the turn of our 50th year, we should recognize the tremendous growth and influence we have had not only in EM but in the entire healthcare system at a national level. Honoring that growth, we also remain vigilant, building our practice and our leaders for the next 50 years.

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Interview with ACEP Past President Gregory L. Henry, MD, FACEP https://www.acepnow.com/article/interview-with-acep-past-president-gregory-l-henry-md-facep/ https://www.acepnow.com/article/interview-with-acep-past-president-gregory-l-henry-md-facep/#respond Wed, 19 Sep 2018 14:58:00 +0000 https://www.acepnow.com/?post_type=article&p=19617 As part of our celebration of ACEP’s 50th anniversary, ACEP Now Medical Editor-in-Chief Kevin Klauer, DO, EJD,...

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As part of our celebration of ACEP’s 50th anniversary, ACEP Now Medical Editor-in-Chief Kevin Klauer, DO, EJD, FACEP, recently sat down with ACEP Past President Gregory L. Henry, MD, FACEP, clinical professor in the department of emergency medicine at the University of Michigan Medical School in Ann Arbor, to discuss key moments in ACEP’s history and to consider what might be in store for ACEP’s future. Here are some highlights from their conversation.

KK: I’m so excited to culminate the 50th anniversary series with, you, Dr. Henry. You always have words of wisdom in many circumstances. Over the course of your time with ACEP, what are some notable points in history regarding the specialty?

Dr. Greg Henry

Dr. Greg Henry (Photo: ACEP)

GH: I remember those days [becoming a specialty] clearly because I was living in the Phi Rho Sigma medical fraternity house across the street from St. Joseph Mercy Hospital [in Ann Arbor]. One day in 1968, I went to the ED. The gentleman who would usually let me shadow him [George Fink, MD] was gone.

George had gone to Lansing to sign the papers for a new organization called ACEP. Things had changed in America since the end of the Second World War. There was huge mobility, and lots of people didn’t have doctors. We also learned that we needed to be proactive to change the outcome of certain diseases. Shakespeare said it best: “Diseases desperate grown by desperate appliance are relieved, or not at all.” The emergency departments in the United States had been staffed by fill-in people who were dermatologists, allergists, internal medicine, ob-gyns, etc., who took their turn in the barrel once every month or so. People were starting to realize that was the wrong way to do it. The first critical hour was where emergency care should concentrate its efforts.

Dr. Henry speaks with ACEP members after a presentation.

Dr. Henry speaks with ACEP members after a presentation.

KK: Knowing the criticisms that those initial founders received, what are some of the foundational pieces that helped us to be recognized and respected as a specialty?

GH: The first hurdle was psychological. You had to believe you were as good a doctor as anyone else. The second was that we needed a reasonable training process. The third thing was the first board examination in emergency medicine. We did it better than any other board at that point in time. We really looked at how questions were framed. Were they true discriminators of knowledge, and did they predict success, producing better doctors?

When we moved from being a conjoint board with family practice to a fully independent board, we’d come of age as the 23rd specialty board in the United States.

KK: Is there anything that either helped solidify the foundation of emergency medicine or attempted to destabilize it?

Dr. Henry speaking at past ACEP meetings.

Dr. Henry speaking at past ACEP meetings.

GH: There was no specialty that ever grew as fast as emergency medicine. People saw that it was an intellectual challenge, needing excellent people. The paradox was that excellent people were needed in cities, which weren’t prominent academically. We were needed where the patients were, as one of the first specialties that was truly patient-centered.

As health care becomes more and more complex, our role in resource management and guiding policy is only going to increase. This reflects what citizens of the United States need to receive better health care.

KK: Greg, you’ve been described as the junkyard dog of emergency medicine, because you defended us tirelessly. Do you have a personal story you can share?

GH: One humorous story is about my daughter marrying the son of the chairman of radiology at Duke. This was, at first, an unholy alliance [emergency medicine and radiology], as might be expected. However, as we got more and more into this, the chairman, following insurmountable pressure, made sure that their ultrasonography people were going to train the emergency medicine residents exactly the same as he did the radiology residents. Perhaps, this helped to lessen some political barriers in training and access to point-of-care ultrasound.

As ACEP President, I represented us at the American College of Surgeons. Everyone sitting on the other side of the table from us was a professor at an ivory tower program. Almost none of them actually primarily saw patients. I pointed out, “The thing that you’re most afraid of is us taking your jobs, which is exactly what the surgeons want us to do in the community. They don’t want to be running in for anything unless they’re about to take them to the operating room.”

After we got our barbs, comments, and Shakespearean quotes out, they said, “You know, you may have something there and it may be important.” In the old days, all the trauma resuscitation stuff was under the control of surgery. Interestingly, that wasn’t where the surgeons were doing most of their research. Emergency physicians were initially caring for trauma in this country.

KK: Those who do not recognize history are doomed to repeat it. Do you see us revisiting history?

Dr. Henry speaking at past ACEP meetings.

Dr. Henry speaking at past ACEP meetings.

GH: We went from, early after the Second World War, seeing 20 million emergency visits to now something around 140 million visits or more. We can’t rest on our laurels. We’ve built a specialty, but the work of the next half century is just beginning. Innovative care models are being contemplated and designed. I think that our people are superbly trained and experienced to handle many of these situations [eg, telemedicine]. If we don’t pursue this with the same vitality, we can be sucked up and blown away with the tide of history by other people who want to get into these areas as well.

I’m spending time with people who are looking at health care in America and why it’s costing us two or three times more to take care of patients than it costs elsewhere. They are asking important questions, which we should be anticipating. We need to be on the side of history, figuring out how to provide better care for less money, with less utilization of expensive technology.

KK: Where do you see emergency medicine in the future?

GH: We are going to have to evaluate the medical educational system. Many countries in the world do not send you for four years to get a degree before you start your medical training. What role will [physician assistants, nurse practitioners, emergency medical technicians,] etc.] play, and how should we guide this? I see emergency physicians of the future being more involved in thinking and providing opinions than just sewing up wounds. For example, physicians don’t need to repair most lacerations. The business world and consumers will continue to pose questions of value that we must be prepared to answer.

KK: Any words of wisdom for younger emergency physicians for a successful and fulfilling career?

GH: The best way that the young physician coming up can handle burnout is to like what you do for a living. I love my work and always have.

I think we need to start programming and help our young docs program themselves to have a logical progression of their career. You start out on midnights wrestling intoxicated patients. You may end up running a telemedicine service that covers half the state of Montana. The way we fight burnout and this feeling that we’re not accomplishing anything is to always have another goal, something we’re going to do to expand and revitalize our careers.

KK: Greg, any final thoughts?

GH: Well, I go back a long time. As you remember, I took care of Lincoln and that didn’t go well. If we become entrenched in how we do things without looking ahead to ask new questions, and we can’t define the goal as improving health care, then we’re on a road to nowhere. If we continuously look at what actually makes a difference in how patients turn out, then we’re going to be where we need to be to have both the American people and the house of medicine on our side.

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ACEP-Led Provision Boosts Prescription Drug Monitoring Programs https://www.acepnow.com/article/acep-led-provision-boosts-prescription-drug-monitoring-programs/ https://www.acepnow.com/article/acep-led-provision-boosts-prescription-drug-monitoring-programs/#respond Wed, 19 Sep 2018 14:58:00 +0000 https://www.acepnow.com/?post_type=article&p=19621 An ACEP-developed provision that requires the Department of Defense to share controlled substance prescribing information of TRICARE...

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An ACEP-developed provision that requires the Department of Defense to share controlled substance prescribing information of TRICARE beneficiaries with state prescription drug monitoring programs was successfully passed into law as part of H.R. 5515, the John S. McCain National Defense Authorization Act for Fiscal Year 2019. ACEP staff worked closely with Rep. Mike Turner (D-OH) to develop this legislative effort and ensure its inclusion in this year’s defense authorization bill.

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ACEP Teams Up to Improve ED Sickle Cell Disease Care https://www.acepnow.com/article/acep-teams-up-to-improve-ed-sickle-cell-disease-care/ https://www.acepnow.com/article/acep-teams-up-to-improve-ed-sickle-cell-disease-care/#respond Wed, 19 Sep 2018 14:58:00 +0000 https://www.acepnow.com/?post_type=article&p=19623 The Emergency Department Sickle Cell Care Coalition (EDSC3) hosted a one-day leadership summit on Aug. 16, 2018,...

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The Emergency Department Sickle Cell Care Coalition (EDSC3) hosted a one-day leadership summit on Aug. 16, 2018, at the American Society of Hematology’s headquarters in Washington, D.C. The purpose of this summit was to identify concrete and specific actions to improve care in the emergency department for children and adults living with sickle cell disease (SCD). A variety of leaders from key organizations discussed current initiatives and how to collaborate to effectively and efficiently disseminate best practices to improve the emergency department care for children and adults with SCD. The keynote address was presented by Adm. Brett P. Giroir, MD, assistant secretary for health at the U.S. Department of Health and Human Services.

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The Latest ACEP Advocacy for Physicians and Patients https://www.acepnow.com/article/the-latest-acep-advocacy-for-physicians-and-patients/ https://www.acepnow.com/article/the-latest-acep-advocacy-for-physicians-and-patients/#respond Wed, 19 Sep 2018 14:57:59 +0000 https://www.acepnow.com/?post_type=article&p=19625 ACEP was invited by AHIP, a trade association for commercial insurers, to participate in a meeting of...

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  • ACEP Adm. Brett P. Giroir, MD, delivers the keynote address at the Emergency Department Sickle Cell Care Coalition summit.

    ACEP
    Adm. Brett P. Giroir, MD, delivers the keynote address at the Emergency Department Sickle Cell Care Coalition summit.

    ACEP was invited by AHIP, a trade association for commercial insurers, to participate in a meeting of payers seeking input on expanding use of non-opioid pain management. Other physician groups invited to participate were the American Medical Association (AMA), American College of Physicians, and American Academy of Family Physicians.

  • ACEP contributed information to, and coordinated with, Sen. Claire McCaskill (D-MO) on her report detailing Anthem’s retroactive denials of emergency care coverage that was released late last month. (See page 6 for more on ACEP’s efforts to combat retroactive denials of emergency department visits.)
  • ACEP participated by invitation in a convening by the White House’s Office of National Drug Control Policy on efforts to address the opioid epidemic. 
  • ACEP participated by invitation in a roundtable discussion on health care price transparency initiated by Senators Bill Cassidy (R-LA), Michael Bennet (D-CO), Chuck Grassley (R-IA), Tom Carper (D-DE), Todd Young (R-IN), and Claire McCaskill (D-MO). ACEP was one of only three physician associations in attendance, joining the AMA and the American College of Surgeons. Among the other groups participating were the American Hospital Association, insurers and brokers, and patient advocates.
  • ACEP was the only medical association invited to participate in a meeting on price transparency at the Department of Health and Human Services. Demetrios Kouzoukas, principal deputy administrator of the Centers for Medicare and Medicaid Services (CMS) and director of the Center for Medicare, attended the majority of the session. 
  • ACEP attended multiple listening sessions with CMS to discuss proposals related to the 2019 Physician Fee Schedule and Quality Payment Program Proposed Rule.
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    Dr. Christina Maslach Discusses the Roots of Burnout https://www.acepnow.com/article/dr-christina-maslach-discusses-the-roots-of-burnout/ https://www.acepnow.com/article/dr-christina-maslach-discusses-the-roots-of-burnout/#respond Wed, 19 Sep 2018 14:57:59 +0000 https://www.acepnow.com/?post_type=article&p=19635 When Christina Maslach, PhD, started her psychology research career in the early 1970s, she didn’t know that...

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    LEFT: Image from the cover of the issue of Human Behavior magazine where Dr. Maslach published her first article in 1976. RIGHT: Cover of Burnout: The Cost of Caring, published in 1982.

    TOP: Image from the cover of the issue of Human Behavior magazine where Dr. Maslach published her first article in 1976.
    BOTTOM: Cover of Burnout: The Cost of Caring, published in 1982.
    PHOTOS: Christina Maslach

    When Christina Maslach, PhD, started her psychology research career in the early 1970s, she didn’t know that her work would lead to the Maslach Burnout Inventory, a measure for professional burnout that’s still being used today. She first published the inventory with coauthor Susan E. Jackson in 1981. Dr. Maslach, who is professor of psychology at the University of California, Berkeley, has researched and published extensively about burnout throughout her career, and has helped to define the way we discuss and understand the combination of stress, exhaustion, and powerlessness that endangers the careers—and lives—of many emergency physicians.

    ACEP Now Medical Editor-in-Chief Kevin Klauer, DO, EJD, FACEP, recently sat down with Dr. Maslach to discuss the early research that led to her developing the Maslach Burnout Inventory and what she’s learned from decades of talking to people about burnout. Here is Part 1 of their conversation. Part 2 will appear in the October issue.

    KK: Tell us how your background led you to work on this particularly important topic.

    CM: I received a PhD in social psychology from Stanford University, and then I took a job at the University of California at Berkeley, where I’ve been for the rest of my career. I had done research on emotion while I was in the doctoral program, particularly focusing on how people dealt with some of the emotional challenges or crises they might experience.

    At Berkeley, I wasn’t able to start doing my research because they hadn’t yet provided me with a research facility. So, I thought I’d go and interview some people who might give me some insight into their experience. From that, I would develop some hypotheses and research and so forth. I started interviewing some people who I thought might face these kinds of emotional challenges. I was talking with, in terms of health care, for example, physicians who were working in emergency departments, with oncology wards, and nurses—and people would keep referring me to somebody else—just talking to psychiatric nurses, police officers, ministers, and different people who sometimes had some very difficult situations.

    What I found in the interviews was very serendipitous. I had never heard about burnout. I wasn’t talking about burnout, but what was happening in the interviews is that people would say, “Here’s what’s happening. I know this is confidential, so I’ve never really said much about it to anybody, but …” Then they would be describing their particular story, and what I found was there was a kind of a rhythm to the story; there were some fairly common themes.

    One day, I was talking with someone who had been working in poverty law, and she said, “That sounds familiar. I don’t know what they call it elsewhere, but we call it burnout.” I would ask people at the end of the interview if they ever describe this to other people, and if so, how did they talk about. I never got much of an answer.

    I described some concepts that appear in sociology, psychology, health literature, and they’d say, “No, no, no.” Then I added, “So, what about burnout?” “Yeah, that’s it, oh my gosh.” What I was finding was it was really not a psychological concept, but it was something that was really a grassroots sort of thing. The people themselves said this term captured what they were feeling. After that I would use “burnout” at the end of the interview to talk with them about it.

    KK: What time frame was this?

    CM: This was in the early to mid ‘70s.

    KK: Did this prompt you to then do the survey?

    Dr. Christina Maslach

    Dr. Christina Maslach

    CM: Yes. All of that work came out of this original experience. I was doing interviews with different people, and then when possible, I would observe them at work to see what their work day was like. I talked to their colleagues, or we talked to spouses of these people. We were trying to get a sense from people who knew this person, worked with them, and maybe shared the same kind of experiences. Although it wasn’t something that I had intended to do, or that I set out with a mission to define burnout, but once I stumbled over it, it was clear that there was something really important about this.

    I had a hard time getting published at first. It wasn’t laboratory research like I had been trained to do. My first article about this was written for a popular magazine called Human Behavior. They published it in 1976, and in an interesting way, that was maybe a better spot for all of the things I did on burnout because that generated tons of feedback. These were snail mail days. Tons of letters and phone calls. People would say, “Oh my gosh. I thought I was the only one. Let me tell you my story.” I just felt I had stumbled upon something that was not well-known, not well-recognized. I was told it was pop psychology. People’s experiences inspired me to continue this work, not to abandon other research I was doing, but to add this focus. After a while, it became more and more the main work that I was doing.

    KK: Can you describe how hard it was and what the process was for you to develop the survey or the burnout inventory?

    CM: The problem is that you have to develop a measurement that has evidence proving it is clearly measuring what it is that you say it’s measuring.

    It looks straightforward. People say, “Oh, it’s easy. I’ll just write a few questions of my own.” Well, you have no idea if those questions are working correctly or not. There’s something called face validity, which makes it sound right, but you need to gather other data to really test out which items, questions that you’re using, and formats are really working well to measure what you say is being measured. Psychometric research took years and years of work by me, Susan Jackson, other students, and other colleagues because we had to gather data on so many people in so many different ways to be able to triangulate on, proving that this was the thing that people were talking about [burnout].

    I was fortunate because the professor in psychology who was one of the leading people in assessing psychological constructs was a member of my department, Harrison Golf. He really became my mentor, and made clear to me what it was that I had to do. It was really on-the-job training to do this. It took a long time, but it turned out well, in the sense of meeting all the criteria that you need for such a measure. Even though that was more than 40 years ago, it’s still stood the test of time, and other measures that get developed are always comparing themselves to this standard. It surprises me a bit because I would have thought that people would have updated things or maybe come up with better options or done other sorts of things. I think all the work that we put in at that time has contributed to that.

    KK: Did you have any idea that what you were developing would have the impact that it has today?

    CM: No, not at all. I have to say, way back then, it wasn’t only the editors of journals who would turn my articles away and not even read them because they said, “We don’t publish pop psychology.” It took a long time to get people to believe there was something there.

    KK: Did you ever get discouraged?

    CM: My interest in the topic really was stoked by the experiences of the people that I kept talking to over time, and that’s true even now. I’d be interviewing people, and they were getting angry and upset, and they’re crying. This was not something trivial. This really matters. People tell me stories about how this has affected their family and how they’ve made decisions they now wish they hadn’t. It was something that fascinated me.

    The post Dr. Christina Maslach Discusses the Roots of Burnout appeared first on ACEP Now.

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    ACEP Sues Insurer for Retroactive Denials of Emergency Department Visits https://www.acepnow.com/article/acep-sues-insurer-for-retroactive-denials-of-emergency-department-visits/ https://www.acepnow.com/article/acep-sues-insurer-for-retroactive-denials-of-emergency-department-visits/#respond Wed, 19 Sep 2018 14:57:59 +0000 https://www.acepnow.com/?post_type=article&p=19629 In its escalating fight against Anthem BlueCross BlueShield’s dangerous policy of retroactive denials of ED visits the...

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    ILLUSTRATION: Chris Whissen   PHOTOS: shutterstock.com

    ILLUSTRATION: Chris Whissen PHOTOS: shutterstock.com

    In its escalating fight against Anthem BlueCross BlueShield’s dangerous policy of retroactive denials of ED visits the insurer deems as “non-emergent,” ACEP has taken legal action. Joined by the Medical Association of Georgia, ACEP filed a lawsuit against Anthem’s BlueCross BlueShield of Georgia in July 2018 in federal court.

    This action follows a yearlong effort by ACEP to protect the prudent layperson standard on behalf of its members and fight back against the policy that Anthem currently is enforcing in six states. These efforts have yielded significant progress: Anthem announced in February that it was expanding the “always pay exceptions” on the denials policy and would request a medical record for every potential denial; The New York Times ran a story on reactions to Anthem’s policy that featured data contributed by ACEP on denials in each state the policy was implemented in; and most recently, Sen. Claire McCaskill (D-MO) published a report on the Anthem issue for which ACEP also contributed information.

    But even with Anthem’s changes to the policy, lives are still being endangered merely by its continued existence. Anthem policyholders are still being told by the insurer to “save the ER for emergencies, or you’ll be responsible for the cost.” Yet, as we all know, it is often impossible for emergency physicians, much less patients, to know based on a patient’s initial symptoms whether their condition will ultimately end up being emergent. Therefore, since Anthem continues to force patients to second-guess the decision to seek emergency care, ACEP and its leadership determined that further action was needed.

    ACEP’s lawsuit asserts that Anthem’s policy violates the prudent layperson standard, which requires insurance companies to cover the costs of emergency department visits based on a patient’s symptoms and not the final diagnosis. Further, because the policy discriminates against those in protected classes, who utilize emergency departments more frequently and are disproportionally impacted by the financial stress created by having their claims denied, Anthem is also being sued for a violation of the 1964 Civil Rights Act. The lawsuit requests the court grant an injunction preventing Anthem from enforcing its destructive denial policy or retroactively denying benefits.

    Stopping Anthem’s retroactive ED denials policy with this lawsuit is critical to protecting the prudent layperson standard and working to ensure other payers do not follow with their own similar dangerous policies. ACEP is currently also fighting back against BlueCross BlueShield of Texas’ new policy to deny coverage for its HMO patients who seek care for what it deems as non-emergent conditions at an out-of-network facility, as well as Medicaid managed care plans and state waiver applications that also erode the prudent layperson standard. ACEP continues to engage in efforts with federal policymakers to strengthen that standard and ensure it is appropriately enforced, as required under federal law.


    Ms. Wooster is ACEP’s associate executive director of public affairs. Ms. Moore is ACEP’s general counsel

    .

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    Is a Two-Physician Marriage Double the Challenge or Double the Fun? https://www.acepnow.com/article/is-a-two-physician-marriage-double-the-challenge-or-double-the-fun/ https://www.acepnow.com/article/is-a-two-physician-marriage-double-the-challenge-or-double-the-fun/#respond Wed, 19 Sep 2018 14:57:58 +0000 https://www.acepnow.com/?post_type=article&p=19637 Being a physician can make relationships challenging—long hours, high stress, and the danger of burnout can tax...

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    Being a physician can make relationships challenging—long hours, high stress, and the danger of burnout can tax even a strong marriage. But what happens when both spouses are physicians?

    Dr. O’Shea and Dr. Benzoni at a recent conference.

    Dr. O’Shea and Dr. Benzoni at a recent conference.
    PHOTOS: Thomas Benzoni & Noreen O’Shea

    According to Noreen O’Shea, DO, FAAFP, and Thomas Benzoni, DO, FACEP, the challenges of their demanding careers are balanced by the understanding and support of being married to someone who knows exactly what it’s like to provide care in the emergency department. The couple met as undergraduates and got married shortly before Dr. Benzoni started medical school. About 40 years later, they both teach part-time at Des Moines University in Des Moines, Iowa, where Dr. O’Shea also practices at a federally qualified health center and Dr. Benzoni practices at local emergency departments, Level 1 to Level 4.

    The couple recently sat down with ACEP Now Medical Editor in Chief Kevin Klauer, DO, EJD, FACEP, to discuss their experiences of being in a two-physician marriage.

    KK: How long have you two been together?

    NO: According to him, 50-plus years. We will be married 39 years in August.

    KK: How did you two meet? Were you medical students?

    TB: This goes back to Creighton University in a class on world hunger.

    NO: We met when I was sophomore at Creighton. Everybody had to take a philosophy class, and so we were in a philosophy class on world hunger together.

    TB: After our honeymoon, we could survive anything.

    NO: We had a difficult honeymoon. We were camping on the Current River in southern Missouri and were attacked by horseflies and had a bout of Montezuma’s revenge.

    TB: Yeah. Don’t give your wife salmonella poisoning on your honeymoon. That’s the only advice I’ll give you.

    NO: We got married three weeks before he started medical school. And then I didn’t start medical school until a year after him.

    Dr. O’Shea (LEFT) and Dr. Benzoni (RIGHT) with two of their children.

    Dr. O’Shea (LEFT) and Dr. Benzoni (RIGHT) with two of their children.

    KK: Have you both always practiced emergency medicine?

    TB: That’s the only thing I know how to do. The chapter after Creighton is even more formative. Noreen was assigned with the Public Health Service to the Appalachian Mountains. We spent four years in Appalachia and built a hospital where there hadn’t been one.

    NO: I’ve been practicing family medicine, but I have done, in order to keep my skills up, one or two days a month in the emergency department.

    KK: Tell us about the dynamic and intricacies of a two-physician marriage.

    TB: To me, the big advantage is that Noreen understands that I’m in a 24-7-365 business and that sometimes when I come home, I’m a grumpy old bastard, and sometimes when I come home, it’s been a really good day. Most of the days are in between.

    KK: It has to be very helpful for somebody to have a fundamental understanding of what the environment is like and what the practice is like.

    NO: It also started while we were in medical school. He understood when I felt like I had to study. And he could understand the stresses but also share in the joys.

    KK: What are some of the challenges or obstacles of being together as a two-physician team?

    TB: A challenge is the opposite side of an opportunity. Just going along chronologically, our oldest [our daughter] was born while we were in Michigan. Having children created some scheduling challenges. The department would have these Saturday morning meetings. Well, we both had to be there, so we’d bring her along. People looked at us funny because you didn’t do that in those days. But we hadn’t seen her all week, so she’s coming with us anyway.

    A lot of things just happened to work out if you were willing to get a little bit of grace back and forth. I still send Noreen my proposed schedule, and she gets to veto anything that she wants.

    We tried for a while for each of us maintain our own calendars, and you can guess how that worked out. So she’s in charge of the calendar.

    NO: And sometimes if I didn’t write it down or I made a mistake on the calendar, we would get a call an hour or half hour after the shift was supposed to have started, “Tom, where are ya?”

    TB: In 35 years of doing that, that’s only happened twice.

    KK: Noreen, tell us about some challenges from your perspective.

    NO: I don’t type that well, so when I can’t dictate because of the structure of the electronic medical record [EMR], I spend a lot more time doing pajama time at home, charting on my patients. He doesn’t have that luxury [to delay charting] in the ED the same way I do. Sometimes, he’s aggravated about it, but he’s more often my champion. We share frustrations about EMRs.

    Dr. O’Shea and Dr. Benzoni at their wedding.

    Dr. O’Shea and Dr. Benzoni at their wedding.

    KK: It’s difficult enough for someone to be with one physician, but both of you together as physicians in a relationship has to be very complicated. Did you ever get to the point where you thought it was just going to be too hard?

    TB: I’ve always been a bit of a realist about it. I know I’m really hard to get along with, so I just figure, with a lot of forgiveness, it goes the other way, too.

    NO: We did have a time that was really difficult. There was a lot of pressure externally when he was part of an independent group about 10 years ago. They got down to staffing a very busy Level 2 emergency department with four guys. That was really hard because he and all the rest of them were working so, so hard. That’s a reason, among others, we moved to Des Moines to be out of that hot pressure-cooker situation where he was taking on so much responsibility and so many shifts.

    KK: It sounds like that was a turning point for you, too, that if it continued, it could have put your relationship in jeopardy?

    TB: By then, the kids were gone. They were all out of the house, and I didn’t see any reason to keep working that hard either. Maintaining the relationship is so important. I often tell people—they think I’m being snarky about it, and it’s only partly true—39 years of marriage and not having to pay a divorce lawyer really gives us a lot of freedom.

    NO: I feel like, as a family physician, I can defend emergency physicians and how difficult their work is because not only do I live with one and see that, but I also have worked in the emergency department. Part of my role as a physician’s spouse is to represent my spouse’s specialty in a positive manner. He has also done the same thing.

    KK: Can you offer a couple of thoughts for people who may be earlier in their relationships? If you’re going be with a physician or if you’re going to be in a two-physician relationship, how can you make that work?

    TB: For me, it’s really easy. Bring in the same attitude you do to work. You have to learn to live, and you have to learn to give some and deemphasize yourself. If you’re fighting, you’re probably not fighting for anything important anyway.

    NO: We would make sure we’d get to the kids’ games or whatever was happening at school. He was able in his group to arrange the schedules so that any of his partners or he could make it at the beginning or the end of the school play. Making time for each other and family is really important.

    We also find great joy in being part of local medical societies and supporting other physician couples or even couples that are one physician and a non-physician spouse. That has been really helpful.

    KK: How many kids do you have?

    TB: Want some? Four of them.

    KK: I’m sure you wouldn’t give any of them up. How old are they?

    NO: One is 33. She’ll be 34 in September. The rest are 30, 28, and 25. Our 28-year-old is in her EM residency.

    KK: I’ve learned from listening to you two that despite the fact that it can be challenging in any relationship, you have to find ways to make it work, to find the positives, and to overcome the negatives. You two have been very successful in doing that. Thank you very much for your time and congratulations on all of your successes.

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    2018-2019 Compensation Report for Emergency Physicians https://www.acepnow.com/article/2018-2019-compensation-report-for-emergency-physicians/ https://www.acepnow.com/article/2018-2019-compensation-report-for-emergency-physicians/#respond Wed, 19 Sep 2018 14:57:58 +0000 https://www.acepnow.com/?post_type=article&p=19641 The national average salary for emergency physicians increased again this past year, a full 3.5 percent. Not...

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    The national average salary for emergency physicians increased again this past year, a full 3.5 percent. Not a stunning number, but when you add it into the trend of the past 10 years, it reflects a 34.5 percent increase for emergency physician salaries over the past 11 years.

    How is it happening? States that have been chronically low-paying historically are starting to climb. In New York, for instance, starting salaries increased 25 percent this year. Even the West saw dramatic increases, with salaries up 32 percent in Nevada and 14 percent in New Mexico.

    The Midwest continues to be all over the map, with increases in Michigan (11 percent), Minnesota (12 percent), and Ohio (14 percent) and a big decrease in Kansas of 18 percent. The Mid-Atlantic states experienced a 17 percent increase overall, including a 20 percent hike in the District of Columbia. The Pacific Northwest posted a 15 percent increase in Montana and 14 percent in Washington.

    Another important number is the percentage of job opportunities open to physicians with primary care board certification (PC-BC). Currently, this is 43 percent! With nearly half the country’s emergency medicine jobs open to physicians not trained in emergency medicine, we have further evidence of the location-driven supply and demand market in the specialty. I see this number increasing in the next five years.

    Trends and developments this year include:

    • Urgent care salaries are creeping up and, in some cases, pay as much or even more than emergency physician incomes in some states.
    • Sign-on bonuses continue to grow, with $50,000 a norm and a high between $120,000 and $150,000 in geographically challenged areas.
    • Broad salary ranges continue in some states, such as $116–$300 an hour in Pennsylvania and $160–$282 an hour in Minnesota.
    • The highest dollars in emergency medicine occur in locum tenens offers, with the $300–$320 an hour appearing more frequently. I even found one location offering $350 an hour in North Dakota.
    • Only eight states provide no options for PC-BC physicians this year.

    The following numbers are based on working 1,632 clinical hours a year and include incentive bonuses and relative value unit compensation, where applicable. Annual package numbers include basic benefits valued at $30,000. Sign-on bonuses, loan assistance, and other perks are not included. Rankings are based on state averages, not highs and lows.

    The Southeast once again leads the country with a regional average of $236 per hour/$416,000 a year. It also nearly leads the country in opportunities open to physicians with PC-BC at 54 percent, up 26 percent from last year

    Mississippi: Average: $265/hr., $463,000 ann.; 50% PC-BC; high of $300/hr.; no change South Carolina: Average: $253/hr., $444,000 ann.; 54% PC-BC; high of $500,000 ann.; up 7%
    Georgia: Average: $238/hr., $418,000 ann.; 71% PC-BC; high of $300/hr.; up 6%
    Tennessee: Average: $234/hr., $412,000 ann.; 75% PC-BC; no real highs; no change
    Alabama: Average: $234/hr., $412,000 ann.; 25% PC-BC; high of $500,000 ann.; up 10%
    North Carolina: Average: $228/hr., $402,000 ann.; 51% PC-BC; no real highs; up 8%
    Arkansas: Average: $226/hr., $400,000 ann.; 100% PC-BC; no real highs; no change
    Louisiana: Average: $225/hr., $397,000 ann.; 33% PC-BC; no real highs; down 7%
    Florida: Average: $225/hr., $397,000 ann.; 25% PC-BC; high of $350/hr.; no change


    The Southwest/West comes in second with a regional annual average of $220 per hour/$389,000 a year, up 10 percent from last year. Opportunities open to physicians with PC-BC are at 50 percent, up 8 percent.

    New Mexico: Average: $271/hr., $472,000 ann.; 50% PC-BC; high of $533,000 ann.; up 14%
    Nevada: Average: $248/hr., $434,000 ann.; 40% PC-BC; no real highs; up 32%
    Texas: Average: $247/hr., $434,000 ann.; 43% PC-BC; high of $320/hr.; down 9%
    California: Average: $228/hr., $402,000 ann.; 52% PC-BC; high of $520,000 ann.; no change
    Arizona: Average: $218/hr., $386,000 ann.; 53% PC-BC; high of $500,000 ann.; no change
    Oklahoma: Average: $203/hr., $362,000 ann.; 70% PC-BC; high of $500,000 ann.; no change
    Hawaii: Average: $180/hr., $324,000 ann.; 0% PC-BC; no real highs; no change
    Colorado: Average: $165/hr., $300,000 ann.; 40% PC-BC; high of $210/hr.; no change
    Utah: No jobs open or information available


    The 13 states of the Midwest have a $212 per hour/$377,000 a year regional average, with 52 percent of the jobs open to physicians with PC-BC.

    North Dakota: Average: $233/hr., $410,000 ann.; 0% PC-BC; high of $350/hr. (locum tenens); no change
    Illinois: Average: $232/hr., $408,000 ann.; 45% PC-BC; high of $500,000 ann.; up 5%
    Ohio: Average: $231/hr., $407,000 ann.; 56% PC-BC; high of $312/hr.; up 14%
    Kentucky: Average: $230/hr., $405,000 ann.; 66% PC-BC; high of $487,000 ann.; down 3%
    Indiana: Average: $230/hr., $405,000 ann.; 50% PC-BC; no real highs; no change
    Wisconsin: Average: $215/hr., $380,000 ann.; 53% PC-BC; high of $520,000 ann.; no change
    Missouri: Average: $206/hr., $367,000 ann.; 52% PC-BC; no real highs; no change
    Minnesota: Average: $201/hr., $358,000 ann.; 58% PC-BC; high of $489,000 ann.; up 12%
    Michigan: Average: $196/hr., $350,000 ann.; 76% PC-BC; no real highs; up 11%
    Iowa: Average: $195/hr., $348,000 ann.; 55% PC-BC; no real highs; up 6%
    Kansas: Average: $193/hr., $344,000 ann.; 66% PC-BC; no real highs; down 18%
    Nebraska: Average: $190/hr., $340,000 ann.; 45% PC-BC; no real highs; no change
    South Dakota: No jobs open or information available


    For the first time, the Pacific Northwest is fourth regionally instead of last, with an average of $200 per hour/$357,000 a year due to increases in Montana and Washington. PC-BC accep­tance is 62 percent, doubled from last year.

    Wyoming: Average: $228/hr., $402,000 ann.; 64% PC-BC; no real highs; no change
    Idaho: Average: $223/hr., $393,000 ann.; 66% PC-BC; high of $300/hr.; no past information
    Montana: Average: $194/hr., $346,000 ann.; 25% PC-BC; no real highs; up 15%
    Oregon: Average: $182/hr., $328,000 ann.; 52% PC-BC; no real highs; no change
    Washington: Average: $175/hr., $315,000 ann.; 90% PC-BC; no real highs; up 14%
    Alaska: No jobs open or information available


    The seven Mid-Atlantic states come in under the national average at $198 per hour/$353,000 a year, with 29 percent of jobs open to PC-BC.

    Virginia: Average: $243/hr., $426,000 ann.; 38% PC-BC; no real highs; up 3%
    Pennsylvania: Average: $218/hr., $387,000 ann.; 50% PC-BC; high of $520,000 ann.; no change
    New Jersey: Average: $204/hr., $362,000 ann.; 32% PC-BC; no real highs; up 9%
    West Virginia: Average: $194/hr., $346,000 ann.; 60% PC-BC; no real highs; no change
    Maryland: Average: $184/hr., $330,000 ann.; 25% PC-BC; no real highs; up 10%
    District of Columbia: Average: $175/hr., $314,000 ann.; 0% PC-BC; no real highs; up 20%
    Delaware: Average: $165/hr., $300,000 ann.; 0% PC-BC; high of $250/hr. (locum tenens); no change


    In last place, the Northeast continues to drag its feet with a regional average of $186 per hour/$333,000 a year, despite the 25 percent hike in New York salaries. However, this region leads the country with the fewest opportunities for PC-BC at only 13 percent.

    New York: Average: $208/hr., $370,000 ann.; 37% PC-BC; high of $479,000 ann.; up 25%
    Massachusetts: Average: $186/hr., $333,000 ann.; 0% PC-BC; no real highs; no change
    Vermont: Average: $184/hr., $330,000 ann.; 0% PC-BC; no real highs; no change
    Maine: Average: $180/hr., $324,000 ann.; 25% PC-BC; no real highs; no change
    Connecticut: Average: $179/hr., $322,000 ann.; 0% PC-BC; high of $275/hr. (locum tenens); no change
    New Hampshire: Average: $178/hr., $320,000 ann.; 15% PC-BC; high of $400,000 ann.; no change
    Rhode Island: No jobs open or information available

    Figure 1. States Offering the Most and Least Compensation

    Figure 1. States Offering the Most and Least Compensation


    Ms. Katz is president of The Katz Company EMC, a member of ACEP’s Workforce and Career sections, and a frequent speaker and faculty at conferences and residency programs. Contact her at katzco@cox.net.

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