Council of Emergency Medicine Residency Directors

12:00-1:00 pm	Lunch (all CORD members invited to attend) and announcement of CPC Winners
1:00-2:00 pm	Business Meeting
2:00-3:30 pm	Resident Remediation Panel Discussion, Judith Brillman, MD, Moderator; Robert McNamara, MD; Larry Ornate, MD; and Vicki Gotkin, JD
3:30-4:30 pm	Round Table Discussion: Resident Remediation and Substance Abuse Issues: Substance Abuse Issues, Robert McNamara, MD Psychiatric Counselling and Testing, Larry Ornate, MD Legal Issues, Vicki Gotkin, JD

Final CPC Competition

CORD members are encouraged to attend the Final CPC Competition which will be held on Wednesday, October 13 at 8:00-11:30 am in the N243 Room of the Las Vegas Convention Center. The Best Presenter and Best Discussant winners will be announced during the CORD Meeting which will begin at 12:00 noon.

Cord WebPage and Listservs

The Technology Committee is currently working to enhance the capabilities of both the WebPage and the Listserv. Suggestions can be sent to the committee via e-mail to krodgers@clarian.com(please do not use the Listserv). The committee is also working with the Board of Directors to develop guidelines for use of the Listserv including the rules of etiquette.

There has been a recent increase in Listserv traffic concerning access to the Listserv. If you are a CORD member (each program can designate 3 members) and you are not sure if you are on the Listserv, please e-mail the CORD office at cord@cordem.org. The office will confirm your membership and add you to the Listserv (if you are not already a subscriber). The Listserv can be accessed via the e-mail address cord@toto.com.

If you are a CORD member and would like to have your e-mail address posted on the WebPage under your program listing, please give us your permission and e-mail address by notifying the CORD office at cord@cordem.org. If you would also like to have your picture appear, please send us a quality passport photo or digital photo and we will post it on the WebPage.

Other CORD Listservs of interest include one for chief residents (chiefres@toto.com), medical students (medstuedu@toto.com), and residency coordinators and secretaries (ressec@toto.com). Individuals wishing to subscribe should send an e-mail to the CORD office at cord@cordem.org.

President's Message

"There's More Power in a Vacuum"

Why do residents moonlight? Did you? What is the policy of your program now? How many times have you asked a resident to stop moonlighting secondary to performance problems within the program? Has your state board removed a resident from your program or restricted their practice due to a disciplinary action? Do you accept physicians into your program for "specialty rehabilitation" as directed by your state board?

Some of these questions may become meaningless and others will become quite important if your state adopts the Federation of State Medical Board's recommendations. The recommendations contain several controversial issues with tremendous potential impact to your administrative duties and your future residents. If you are not familiar with the recommendations I would recommend you review them on the Federation's web-site. http://www.fsmb.org/uniform.htm

The FSMB defends its development of the recommendations because of a "grave threat" to the current state-based power structure in licensing and disciplining physicians. They lament that state medical boards have been exposed to criticism for lacking the flexibility to adapt to "changes that have been brought about by new technology and the ever-increasing demand for instant health care." Outside calls for a national-based system of licensing and discipline are therefore at the foundation of the FSMB's reactionary creation of the Special Committee on Uniform Standards and Procedures.

The Special Committee was charged in 1996 to review and evaluate the standards that existed across all the state boards, identify commonalties, and recommend uniform standards that all state boards could agree upon. The committee began its mission by reviewing the existing Federation documents and concluded that positions recommending uniform adoption had already been completed previously. There were "several obstacles," however, that impeded the state boards' adoption of these recommendations. These were: "a general lack of operational autonomy, political constraints arising from difficulties associated with modifying state medical practice acts, and limited funding and staffing levels." The committee also determined that "creating a sense of urgency among member boards toward implementing the existing recommendations" should be part of its task. As far as I can tell the FSMB did not invite the AMA, ACGME, ABMS, AAMC, or any other established professional medical organization to assist them. Not in creating or reviewing the previously created recommendations, nor the new "elements of consistency and uniformity which are not currently in place and which the committee considers vital for member boards to implement as soon as practical." It is clear that in addition to promoting consistency, the FSMB found it desirable to address a perceived lack of quality amongst America's physicians.

The state medical boards do have a right to set standards for independent practicing physicians, including residents. They are held responsible, by society, to protect the public from incompetent and unprofessional physicians. They do this by filtering out less-than-adequate physicians who apply for licensure, dismissing licensed physicians who are found to fail the board's standards, and finally by requiring diversionary and special education experiences as deemed appropriate for the offense. What is clear is that the state boards are now seeking even more capacity to set the definitions, remain vague about due process, and promote board autonomy with regards to all aspects of their function. Public servants, benevolent dictators, or tyrants? Are medical schools ready to re-educate or rehabilitate the graduates who fail to meet the Uniform State board requirements for entering GME programs? Are you prepared to lose a resident or create special education programs for residents who fail a state board standard for aptitude, communication skills, or motivation?

Some CORD members, including myself, applaud the "raising of the bar" concept and specifically how it effectively eliminates the moonlighting thorn. What concerns me more is the rest of the package. I believe the state boards, FSMB, physicians and society in general would be better served by an open dialogue and cooperation rather than "operational autonomy" which seems to me thus far to be an authoritarian operational vacuum. Nonetheless we must face reality and the CORD board will soon finish a position statement on the recommendations. I hope they listen.

Sam Keim, MD
University of Arizona

Report from CORD Subcommittee on GME Funding

During the past two years, our subcommittee has met on several occasions to discuss issues vital to our residency training programs regarding GME funding. We were particularly interested in how the recent HCFA changes in December, 1996 have impacted emergency medicine (EM) residency programs. We therefore surveyed all residency programs in late 1998. The preliminary results of this survey were presented at the CORD meeting in May, 1999. What follows is a summary of the results of that presentation. Currently we are in the process of updating and tabulating all results including a few stragglers and intend to submit these results to Academic Emergency Medicine for publication.

The total number of programs surveyed as of May 1999 was 109 of the 122 EM residency programs. Remarkably according to our survey few programs had planned to decrease in their size since 1996 (4/109) (4%), however, 39% mentioned that there were ongoing discussions regarding decreasing the size of their residency programs at their institution. Approximately 34% of programs mentioned that other programs in their institution had already decreased the size of their training programs. A significant number of programs (26%) either anticipated problems or had already experienced problems with rotations in other institutions due to that institution's resident cap.

A significant number of programs (26 or 24%) also mentioned that since December 1996 there has been a decrease in the number of non-EM rotating residents in their departments. The effect on these programs varied from increasing resident time in the emergency department to increasing attending times or to having more physician extenders.

Only seven (6%) of programs paid resident salaries from their practice plan with an average level of support of 13%. The majority of EM programs have full resident salaries and benefits paid by the institution. Despite the fact that four year programs are only reimbursed at a 50% rate for the fourth year of training (HCFA December, 1996), 97% of four year programs reported that the institution continues to pay full salary and benefits for the fourth year of graduate medical education.

We also explored the issue regarding the HCFA guidelines where institutions are reimbursed at a rate of 50% when the residents exceed their original period of residency training. Eighty-two programs (77%) reported that their institutions continue to take residents with previous training whereas 24 programs (23%) reported that they do not take residents with previous training. Some programs also had limits as to how much previous training was acceptable.

Nearly all programs mentioned receiving close to 100% full support from outside institutions when their residents rotated outside the base institution.

The average DME per resident given by program directors was $48,694.00 (standard deviation equals $37,416, range 5,500 to 180,000). The average IME per resident was $60,740 (standard deviation $36,420, range 19,000 to 180,000).

The positive conclusions from this survey were that emergency medicine appears to be doing very well compared to other specialties with few decreases in program size although there have been frequent discussions regarding this issue. Most EM programs (81%) do use multiple hospitals. Most programs (77%) do take residents with previous training and these positions remain fully funded by the base institution. In addition, nearly all four year programs (97%) have full institutional support for the fourth year of training. Also, 82% of the programs obtain full support for EM resident salaries and benefits from their base institution. It also appears that non-clinical rotations such as research, administration, EMS and other networks overseas, are still permitted by most programs and often funded by base institutions.

There were some conclusions that were concerning from this survey. First, approximately 39% of programs had discussions regarding decreasing their size. Second, 26% of EM programs have had a decrease in non-emergency medicine rotators within their department. Also, 26% of programs anticipate or have had difficulty moving rotations between institutions because of funding caps. It is also very clear from this survey that program directors need to improve their education regarding GME funding.

We would like to thank SAEM and CORD for their support and effort in completing this survey.

Dan Martin, MD
Ohio State University

Technology Corner

Tips for Oral Presentations At Scientific Meetings

We chose to present a different spin on technology in this month's Technology Corner. This article by Bill Cordell focuses on "human technology" in providing tips for oral presentations of scientific material. Our ability to present science and research using current presentation software and hardware in an optimal fashion has an infinite impact on how our message is received.

Getting Your Message Across
• In a scientific presentation, the message is describing the methodology you used, your results, and your interpretation and conclusions.
• Don't spend 5 of your 10 minutes on background information.

  Slides

• 35 mm slides are traditionally used in scientific forums. Make sure your slides enhance, rather than detract from, your message.
• As a rule, there should be less than 25 words per slide.
• Avoid complex backgrounds, clichéd clip art, and mixing of too many typefaces.
• Use photographs to break up the monotony of text slides.

  Practicing

• Practice the way you will deliver the presentation.
• Pretend you're facing the audience. (Don't practice facing the screen. That's not how you will present your paper.)
• Speak the words rather than just "saying" them in your mind.
• Spend 75% of your practice time on the first 30 seconds and closing few sentences.
• Script out the first 30 seconds of your presentation. If you get started without stumbling over your words, you'll quickly gain confidence. It's like flying a plane. Once you're in the air, you're on autopilot. It's take-off and landing that are difficult.

  Getting Rid of Jitters

• Scope out the room where your presentation will be given. Stand at the podium and pretend you're facing a packed room.
• Realize that fear is part of any public performance. Use that fear to energize your presentation.
• Avoid drinking caffeine for several hours before your presentation. A full bladder will heighten any agitation.

  Pre-Launch Checklist

• Make sure the slide carousel hub lock and bottom metal pan are locked in place so your slides don't fall out.
• Arrive early to introduce yourself to the moderator and panel discussants. This lets them know you are there and allows you to see the room.

  Stepping Up To The Plate

• Make sure you are facing the microphone and that it is optimally positioned.
• Be aware that every time you lay something down on the podium, the microphone is picking up the noise.
• Don't fiddle with the slide projector cord or other objects.
• Convince the audience that you are having fun. Smile before you begin. (Or at least don't look like a deer caught in headlights.)
• Don't begin by apologizing. For example, don't say, "I'm sorry my slides came out so dark." This only calls attention to your shortcomings.

  Demeanor and Delivery

• Because this is a scientific presentation, the tone is more formal than a classroom lecture.
• Delete sexist and other offensive language.
• Avoid reading your presentation. (An exception to this is when your presentation is being translated from English to another language. You will need to prepare a transcript for the interpreter.)
• Remember to slow down. People tend to speed up their speech when they're before a crowd.

  Timing Is Everything

• For a 10 minute presentation, time your talk to end around 9 minutes.
• Never try to cram 11 minutes worth of material into a 10 minute space by speaking faster. Instead, take out slides, especially those where you have to explain a lot of bulleted points.
• Going over the allocated time is taboo and discourteous. Besides, nobody ever got mad at a presenter for ending too soon.

  Landing Your Presentation

• Always script out and practice a strong, slightly emotional concluding statement.
• Use pauses and phrasing, where appropriate, for dramatic effect.
• Never end a presentation with a feeble statement such as "Well, that's all I have. Any questions?" Answering Questions From The Audience
• Many persons, once they have finished their presentation, are so relieved that they become garrulous and careless. Remember, you still have up to 5 minutes of questions to field.
• Anticipate questions the audience likely will ask. Write out your answer and rehearse it.
• When it comes to answering questions, pretend you're being cross-examined by a hostile lawyer, and say less.
• Finally, once you're done with questions, there's only one task left ... reward yourself!

William H. Cordell, MD
Methodist Hospital of Indiana

Legal Issues III: Sexual Harassment and Consensual Relationships

Sexual harassment has become a ubiquitous problem in today's society. Not a day goes by that we aren't exposed to another high profile case on television or in the newspapers. But it is not a problem that only affects nationally known personalities, many of us have witnessed or been involved with cases of sexual harassment in our hospitals and residencies. This article summarizes some important concepts reviewed by Vicki Gotkin, Esq. at a recent CORD meeting.

Definition

Sexual harassment is defined as any unwelcome sexual advances, requests for sexual favors, or other verbal / physical conduct of a sexual nature that occurs in the following contexts:

Submission to such conduct is made either explicitly or implicitly a term or condition of an individual's education, employment, or hospital/residency sponsored activity;

Submission to or rejection of such conduct is used as a basis for employment decisions, educational decisions (evaluations/grades), or other decisions affecting an individual's participation in a hospital/residency activity;

Such conduct has the purpose or effect of unreasonably interfering with an individual's work or educational performance or participation in a hospital/residency activity;

Such conduct is sufficiently severe or pervasive to alter the conditions of employment, education, or participation and thus creates a hostile environment.

Responsibilities
1. Residencies and/or sponsoring institutions must have a policy that prohibits sexual harassment
2. An educational program must be in place and available to teach the staff and employees what constitutes sexual harassment, how to prevent it, and what to do if they (victim or staff) suspect sexual harassment has occurred.
3. A written policy must exist which defines the process for reporting and investigating an alleged occurrence of sexual harassment and establish the institutional office (typically the Equal Opportunity and Affirmative Action Office) which will handle the investigation.
4. The policy must prohibit making bad faith allegations of violations of the policy or bad faith false statements in the course of an investigation.
5. The policy must also prohibit retaliation against an individual who reports a possible violation to the Equal Opportunity and Affirmative Action Office or participates in an investigation.
6. Supervisors shall take no disciplinary or contractual action, nor remove an individual from any institutional activity with regard to an alleged policy violation without prior consultation with the Equal Opportunity and Affirmative Action Office. In situations where a supervisor believes there is reasonable danger of imminent serious bodily harm, the supervisor should take immediate, appropriate action to separate the complainant and the alleged harasser including notifying law enforcement officials as needed. Once the individual is safe the Equal Opportunity and Affirmative Action Office should be notified.
7. The Equal Opportunity and Affirmative Action Office (or your equivalent) is responsible for investigating all complaints thoroughly and upon the finding of a policy violation, for issuing recommendations to correct the situation and prevent future policy violations. Recommendations may include counseling/education of the violator or administration action up to and including termination of employment or removal from the educational/residency activity. Individuals alleged to have violated the policy shall be afforded all legally mandated rights, including the right to due process. Confidentiality shall be strictly respected.
8. An employer's only defense to a claim of sexual harassment is if they have provided a comprehensive sexual harassment prevention education/training to their staff and the victim did not follow the procedures for reporting.

We wish to respect the individual's autonomy but also realize that failure to address the situation may result in escalation of the current harassment or harassment of another individual. Add to this the fear of repercussions for failing to make the federally mandated report. This is a very delicate position with no perfect solution. As supervisors we should do everything possible to encourage the individual to report the harassment, but ultimately it becomes the individual's personal decision.

The "Do's" Regarding Claims of Sexual Harassment
• Do properly investigate ALL claims of sexual harassment
• Do have a procedure you follow when such complaints arise
• Do advise the alleged policy violator that a claim has been filed and is being investigated and give them a chance to respond
• Do advise the alleged violator not to retaliate against the complainant
• Do notify the parties involved of the findings of the investigation
• Do take immediate and remedial measures against the violator if sexual harassment has occurred

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