Council of Emergency Medicine Residency Directors

SLOR Revision in the Mail

Dr. Sam Keim has completed the latest version of the Standard Letter of Recommendation and it has been mailed to all programs. Comments and suggestions should be directed to Dr. Keim at . Please contact the CORD office if you do not receive your copy.

Chief Residents' Forum

As you know the SAEM Annual Meeting will be held in Chicago this year. We have several major events planned for residents and are expecting a good turnout. On Saturday, May 16, a full day of events has been scheduled for residents. SAEM, CORD, and EMRA have prepared a well-organized event for newly appointed Chief Residents, "The Chief Resident's Forum." It will be a unique opportunity for chief residents to gain exposure to techniques that will assist them in their new roles. A full day is planned, starting at 7:30 am. Speakers will include Rita Cydulka, Robert McNamara, Steve Hayden, Robert Knopp, Carey Chisholm, Steve Dronen, Sam Keim, and several other academic leaders from the Emergency Medicine community.

The various topics include, Developing Academic and Research Skills, Optimizing Chief Resident Experience, Time Management Skills, Scheduling and Back-Up Systems, Middle Management Techniques, Teaching Skills, How a Residency Works, and several others.

We are expecting 200 participants at the event. Every emergency medicine program will be able to enroll two representative Chief Residents. The event will take place in the Superior Room at the Sheraton Hotel and Towers. Registration and collection of fees will be handled by SAEM. The cost of enrollment is $90 per participant. All organizations involved in this forum have agreed to a non-profit status. All speakers have agreed to cover their own expenses to help minimize cost to participants. Be sure to review the SAEM Annual Meeting brochure for complete details and registration information.

Following the Chief Residents Forum, a panel discussion on the "Future of Emergency Medicine," will begin at 4:30 pm. Speakers for this event will include Peter Rosen, Glenn Hamilton, and Louis Ling. This event will be open to all. The event promises to be an outstanding one, I am sure you will agree.

One final note, the William H. Spivey Research Forum will be held on May 18 at 1:00 pm. Dr. Charles Pollack will speak on "Clinical Interventions in Emergency Medicine." This forum will be open for all that wish to attend. This event was organized by EMRA in conjunction with SAEM. It also, promises to be an outstanding event.

The SAEM Board and program committee have done outstanding work in preparation for the up coming Annual Meeting in Chicago. We are all looking forward to a strong turnout this year. Hope to see you there.

Henry L. Souto, DO
Albert Einstein, Philadelphia

"The Patient as the Teacher"

Professionalism is perhaps the most important element in assuring patient satisfaction. There are many studies concerning patient satisfaction in the emergency department. Some studies delineate the nature of complaints and correlate such things such as waiting times, gender, income and insurance status. Inappropriate, inadequate or omission of therapy, specifically pain medication is a common source of patient complaint. Information sharing through appropriate communications with patients (rapport-hence professionalism) is the best way to ensure patient satisfaction, that is, in addition to appropriate medical care.

Experiences in the emergency department of patient dissatisfaction are sometimes so compelling that they should be utilized as an indelible learning case for the resident involved. I was working in the emergency department recently with a first year off-service resident who assumed that a patient was drug seeking. The 28-year old female patient, who complained of chest pain for 6 weeks, had recently been seen in the emergency department and given Tylenol with codeine. Symptoms of upper respiratory infection had not cleared and the patient continued to cough and was having right side inferior chest pain and right upper quadrant abdominal pain. The work up in the emergency department was essentially negative. My interaction with the patient extended her work up to an ultrasound of the right upper quadrant and an order for pain medication in the department. Subsequent interactions of the resident with the patient was perceived by the patient as progressively negative. When the patient was ready for disposition, the resident indicated that she would not write a prescription for Tylenol with codeine but she would write it for Robitussin with codeine. The patient refused the Robitussin with codeine saying she had already taken Robitussin and the Tylenol with codeine had been helping her pain.

Subsequently, the resident was asked to write a work excuse for the patient. The work excuse was written and the patient was asked to return to work 2 days earlier than the time she was supposed to follow up for care if her symptoms did not abate. This all led to a confrontation at the bedside when the patient essentially blasted the resident for lack of professionalism, lack of caring, insensitivity, etc. Needless to say, the resident was totally embarrassed and at a loss for words. Meanwhile, I saw this coming. Particularly when the resident asked me to write the prescription for Tylenol with codeine when she would not. I took the resident, nurse, patient and her husband to the family room and had a heart to heart discussion. The resident apologized for perception of lack of caring. Follow-up instructions were given to the patient after I had an approximate half hour conversation assuring her that her pain was musculoskeletal and that she would get better.

The patient seemed satisfied with my intervention during her ED visit and follow-up instructions. She did return to the emergency department a few days later still in pain and a subsequent CT of her chest was negative. The patient didn't have rib fractures or radiologic evidence of infection. She had no previous record of drug seeking or drug abuse to my knowledge. This is a familiar scenario to most of us regarding patients in pain. Quality time spent with the patient communicating and caring up front saves a lot of make up time towards the end in terms of apologizing and discussing the qualifications of clinician staff. This case ended with no letters, e-mails and telephone calls that typically occur when patients are dissatisfied.

In this case, I could not have taught the resident any better than the patient did when she discussed the merits of bedside manner. Compassionate pleas from the patient that the resident was rude, cold and uncaring hopefully will have a lasting effect on this particular resident and she will be able to avoid this type of encounter in the future. The resident is a good clinician and had no other untoward patient interactions in the ED.

It's hard to anticipate the type of resident that will enter our program based on our review and interview process. However, we all put a lot of work into trying to get the best fit for our programs. I have witnessed worse interactions than the one I have described, however I will remain ever mindful that lessons often learned by trainees typically have a lasting impact when taught by the patient in contrast to being expounded upon by the mentor. I can appreciate these lessons when they incur little cost to the patient, mentor, and the student. Although it is preferential to have no cost to the patient other than their financial obligations, we as program directors should measure successful training of residents not only in their academic achievements but in lessons learned, lives touched and the moments we share with them along the way.

Marcus Martin, MD
University of Virginia

CPC Regional Competition

The annual CPC Regional Competition will be held on Saturday, May 16 in Chicago. Sixty-eight cases were submitted and 50 selected for presentation. Thanks are due to the 50 resident presenters and 50 faculty presenters who will match wits in the presentation and discussion of interesting cases. There is no registration fee to attend the CPC Competition and all CORD members are urged to attend and support the residency programs.

The regional coordinators and the many judges who will evaluate the presentations will select the Best Discussant and Best Presenter from each of the five competitions. These recipients will be announced during the CPC Reception which will be held at 5:30 pm-6:30 pm and will compete in the National CPC Competition which will be held at the ACEP Scientific Assembly in San Diego on October 13.

This year the CORD staff has requested, and the CPC has been approved for, 7 hours in category I credit. Another good reason to attend the CPC!

Program Director's Workshop

CORD will again sponsor a new program director's workshop on Monday, May 18 from 8:00 am - 12:00 noon. This workshop is open to all CORD members but is designed for assistant program directors and program directors who have been in their position for three years or less. Topics to be presented include academic remediation of residents, mentoring residents, conflict resolution skills, resident reimbursement sources, and psychiatric intervention with problem residents. In addition, time will be available with representatives from ABEM and the RRC-EM for questions and discussions. This workshop is free to CORD members but you are asked to contact the CORD office to pre-register if planning to attend to allow the availability of enough seating and handouts. Debra Perina, MD
University of Virginia

CORD to Meet at ACEP Scientific Assembly

The CORD Meeting will be held at 12:00-6:00 pm on Tuesday?, October 13 in San Diego during the ACEP Scientific Assembly. The ACEP Headquarters hotels are sold out, so please make your travel arrangement soon.

Proceedings Available

Dr. John Howell represented CORD at the December 12-13, 1996 National Symposium on Rapid Identification and Treatment of Acute Stroke. The proceedings have been published and CORD members may obtain copies by contacting the CORD office.

Bylaws Amendments

Each year the CORD Bylaws are reviewed for potential amendments which should be brought before the membership for consideration. On January 26, the CORD Board of Directors approved the following amendments proposed by the Bylaws Committee. The following amendments are provided for the membership's consideration at the annual business meeting on May 18:

Article III, Section 3: Each full member and associate member program shall pay annual dues to the organization an amount to be determined by the Board of Directors. Member privileges will be suspended if dues are six months past due. Membership will terminate if dues are 12 months past due. Any program whose membership has been canceled for failure to pay dues shall lose all privileges of membership.

Article V, Section 6: A. Annual election of officers and members-at-large of the Board shall take place during the semiannual meeting that is held in conjunction with the SAEM meeting. The President shall appoint members to fill vacancies and unexpired terms on the Board of Directors until the next scheduled election.

Article XI: These bylaws may be altered and amended at any time in accordance with Article IV Section 4 of these Bylaws at any properly noticed meeting held for that purpose. proposed amendments shall be submitted in writing to the CORD office by any full member forty five (45) days prior to the meeting.

Unions Hot Topic at ORR Meeting

The Organization of Resident Representatives (ORR) held its annual meeting in conjunction with the annual meeting of the Association of American Medical Colleges (AAMC) at the end of October, 1997, in Washington DC.

Founded in 1991, the purpose of the ORR is to provide a resident voice to the AAMC, and further the training of residents. Members are residents or fellows appointed by the Council of Academic Societies of the AAMC. Two representatives are chosen by each member group. For emergency medicine, this group is the Council of Residency Directors (CORD). In this way the ORR has representatives from almost every specialty.

The agenda of the October meeting included resident unions, election of new officers, and visits to Capitol Hill. Similarly, at the recent AMA-RPS meeting, unionization was also a hot topic.

Unionization of residents has been an issue for twenty years. When the question was put to the National Labor Relations Board in 1976, the NLRB decided that residents were not employees. Consequently, residents were deemed ineligible to bargain collectively as employees.

The issue of unionization was raised again this past fall in Boston. Boston City Hospital's residents have had a union for years. Because Boston City Hospital was a public institution, they could unionize under state law without the right to strike. Boston City and Boston University recently merged to form Boston Medical Center-- a primarily private, not public, entity. The Committee of Interns and Residents (CIR), an affiliate of a national union, approached the residents' union. The CIR wanted to provide collective bargaining for the former Boston City residents' union.

If federal legislation recognizes the residents' union at Boston Medical Center as a private entity, members could strike and allow a third party to negotiate for salaries and benefits. There is concern that the CIR would attempt to negotiate issues such as length of training, required rotations, testing materials, and encourage strikes; thus hindering patient care. The AAMC held multiple and well attended meetings on this subject. These meetings included an open forum with Dr. David Sklar and Dr. Anthony DiBartolomeos from the AAMC, Dr. David Leach, the executive director of the Accreditation Council for Graduate Medical Education (ACGME), and Dr. Randolph Roig, the ORR chair-elect. The multifaceted nature of this quandary was explored.

Overall, participants agreed that the crux of the issue lay in why the Boston residents, and residents nationally, feel they needed unions. In discussion within the ORR, it became evident that residents, especially with our surgical colleagues, are in a uniquely vulnerable position. While some hospitals have resident house staff associations with varying degrees of strength and involvement, many residents have no access to a formal grievance system in which to air their concerns without fear of retribution.

The ORR took the position that residents have a right to bargain collectively. The ORR will encourage the formation of house staff associations at every institution, support local house staff associations and other existing mechanisms in local resolutions of problems, and form a workforce committee to investigate the possibility of a national organization for the local house staff associations.

The ORR suggested to the ACGME that all Residency Review Committees (RRCs) have a resident representative (EMRA provides the emergency medicine resident representative to our RRC). The ORR also suggested that the ACGME change the current guidelines on residents salaries and grievance processes from "should" to "must" be provided to the residents.

The ORR also traveled to near-by Capitol Hill to visit members of Congress. Student loan consolidation and interest deduction, National Health Services scholarship taxation, and other issues were the topics of discussion. The group with which I traveled, led by Dr. Roig, concentrated on non-compete or restrictive covenant clauses and ways to curb their negative impact on contracts.

As elections were held during the meeting, Dr. Roig, the chair-elect, concurrently advanced to the position of chair. Dr. Gail Wehrli, will succeed Dr. Roig as chair-elect. Six members-at-large were elected as well. The ORR showed sincere appreciation to Dr. Cheryl Rucker-Whitaker, the out going chair. Dr. Rucker-Whitaker will remain on the board as immediate-past chair.

The annual meeting of the ORR proved productive and enlightening, with the major issue centering around unionization of residents. I enjoyed participating in a possible solution to the long standing problem of humane residency training. It also became apparent to me and many of my emergency medicine co-residents that we be grateful that emergency medicine residencies have set the standard for treating their residents with respect.

Rebecca Bollinger Parker, MD
Texas Tech-El Paso/Thomason Hospital

Avoiding Legal Pitfalls Related to Residents - Part I
Reference Letters / Summative Letters and Avoiding Claims of Defamation
Hypothetical Case:

A resident, whose performance over the course of three years has been less than stellar, has asked you for a letter of reference. However, none of his formal evaluations reflects this poor performance. Although his ratings fall in the "good" range without notation of specific problems, you are aware that the resident is intimidating as evidenced by several bad interactions with faculty, staff, and patients. You also have knowledge of a malpractice suit in which he exceeded his authority in treating a patient. You are reluctant to give the resident a letter of reference for fear that if you tell the "whole truth", he will sue for defamation.

1. A colleague, from an institution at which the resident has applied for privileges, calls you and asks off the record what the resident is really like. Do you tell the "whole truth" ?
   
   
2. Meanwhile, the resident requests tha t a letter of reference, reflecting only his formal evaluations, be sent to this same individual. Do you write the letter in the manner requested ? Do you make additional comments ? Do you follow up the letter with a phone call revealing the "real story" ? Do you refuse to write the letter ?
   
   
3. Do you have a policy with respect to refer ence letters? Do you have residents sign releases so that you will not have to provide the resident a copy of the reference letter? Does your institution utilize a summative letter at the conclusion of the residency or at significant milestones during the residency that would cover situations in which residents do both well and poorly? Does your state have an immunity statute that insulates you from suit for providing candid employment references?

1. At the conclusion of the residency, or any significant milestone within the residency period, the Program Director should prepare a summative letter that outlines to what extent the resident has mastered each component of clinical competence, including:
   1. Clinical Judgment
   2. Medical Knowledge
   3. Clinical Skills
   4. Humanistic Qualities
   5. Professional Attitudes and Behavior
2. Following a meeting with the resident to discuss the contents of the summative letter, the resident should sign the letter, acknowledging that he/she has had an opportunity to review and discuss it with the program director, and that he/she agrees/disagrees with the content. If, after discussion with the resident, the program director determines that the letter should/could be changed, he /she should do so.
   
   
3. The Graduate Medical Education Committee at your institution should document that each program is preparing a closing/summative letter on each resident. The process of documentation should be included in the internal review that each program has prior to ACGME site visits.
   
   
4. Your institution should develop a separate release of information for the residents to sign prior to graduation.

Requests for Information Related to Employment

1. All requests for information should be documented in the resident s file. A copy of a written request, along with the response to the written request, should suffice to keep a log of inquiries.
   
2. When someone seeks information about a resident, a copy of the summative letter should be sent, without augmentation or verbal comment. A centralized system should be employed so that copies are disseminated only from one source.
   
3. A copy of each letter should be sent to the resident at his/her last known address, which should be on file with the Graduate Medical Education Office.
   
4. State statutes typically provide protection for communications of this sort.

1. Most states require physicians and other healt h care providers to report evidence that a physician is unable to safely engage in the practice of medicine or is guilty of unprofessional conduct to The Board of Medical Examiners or other professional licensing boards. Immunity from suit is usually attached to good faith reports made to professional licensing boards.
   
2. Defamation cases rely upon false statements or statements that are made without regard to the truth or falsity of the statement. Therefore, even though there is no expressed immunity in state statutes for statements made to out-of-state professional boards, you should be protected if the statements made are truthful, factual and clear.
   Adapted from a lecture by Vicki Gotkin, Esq., University of Arizona Health Science Center

   Time Management "Things that matter the most are often held hostage to things that matter the least!"
   
   Time management is more an issue of focus and prioritization than the actual management of time. Often times we find ourselves working hard to accomplish tasks only to find that they were the wrong tasks. It is better to focus on the "compass" and not the clock. Define your direction and develop priority selection based on your mission statement. Maintaining focus on the "mission" results in more efficient productivity.
   
   However, maintaining your focus can be difficult because we have little control over many events that affect our lives. The only thing we have absolute control over is ourselves. Focus on identifying and managing those events that we can control (or how we react to those events). A significant amount of time is wasted trying to control events we have no control over. Additionally, as we work to control those events we can influence, a whole myriad of factors will attempt to derail our focus. These factors are called "time robbers".
   
   Time Robbers
   
   Any attempt at improving time management must include recognition and elimination of "time robbers". These so called "time robbers" may be either external (those imposed by others) or internal (those we impose on ourselves). Here are some common "time robbers".
   
   Interruptions: Interruptions come in three flavors: unnecessary ones which you don't care about; untimely ones that you don't care about right now; and necessary ones that must be dealt with immediately. Determine the interrupter's motivation and evaluate how it fits into your priorities and respond to it accordingly.
   
   Procrastination: Since procrastination is ubiquitous, the most important factor in eliminating it is actually being aware that it's occurring and then determining why you're avoiding a more important task. One solution to procrastination is known as the "cake approach". This solution involves setting a deadline for accomplishing a task, dividing it up into "bitesize" pieces, completing the most difficult pieces first (eating the cake), and rewarding yourself with the easier, more enjoyable tasks last (eating the frosting).
   
   Shifting Priorities: The ability to quickly shift priorities is a valuable tool for managing the ED but is often detrimental in managing one's life outside the ED. Shifting priorities results in less productivity and more wasted time. Establishing clear, prioritized objectives and remaining focused until they are achieved is the cure for this "time robber".
   
   Lack of Planning: Making a "daily plan" and sticking to it is an important part of being focused. This even includes planning for the unexpected. Make sure your plan is consistent with your mission statement and is goal and objective oriented.
   
   Waiting for Answers: An inordinate amount of time is spent waiting for information that someone else controls. Solutions include explaining your priority to those controlling the information, enlisting their support, or seeking alternative sources of information. If these options fail, move on to another priority.
   
   Meetings: How often do you leave a meeting thinking, "That was a waste of my valuable time!" Prior to a meeting establish a concise agenda and a time limit. Be sure to start and end on time. Make sure the correct people are in attendance. Before you attend a meeting, ask yourself this important question, "What would happen if this meeting didn't take place?" If the answer is one you can live with, cancel the meeting or don't attend.
   
   Too Much Work: Learn when to say NO! Knowing your priorities will allow you to efficiently manage your list of jobs and know when "too much" is "too much". When asked to take on another task, reply "I can do this new job, but what do you want me to drop?"
   
   Failure to Delegate: We can all delegate something. However successful delegation doesn't occur by accident. Pick the right person for the job and clearly state the desired outcome. Provide adequate support and backup but don't meddle. Monitor and evaluate the project and provide constructive feedback. Finally, when asked the notorious question, "How do you want me to do this?" reply, "I'll be interested to see what you come up with!"
   
   Paperwork: Prioritize, prioritize, prioritize! Act every time you pick up a piece of paper, either complete the task or put a "mark" on it to identify the number of times you've already attempted to complete the task. Delegate routine paperwork for sorting or handling. Use the "sleeping dog" approach and ask the question, "What would happen if I left this alone .if nothing, throw it out!"
   
   Scheduling: Use your mission statement as the basis for scheduling your life. Schedule a routine planning time and include everything you need to do. Schedule by the month, the week, the day but remain flexible.

   Adapted from a lecture by Michael Gallery, PhD, CAE