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Internal Medicine

Perceptions of X+Y Scheduling Among Combined Internal Medicine-Pediatrics Residency Trainees: A Qualitative … – Cureus

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Internal Medicine

Taskforce works to end racialized differences in medical education and practice – Wayne State University

The Wayne State University School of Medicines End Race-Based Medicine Taskforce is working to dispel and extinguish the misguided belief that individual races are biologically distinct groups determined by genes, and terminate medical practices and research that adhere to that concept.

Co-created by Ijeoma Nnodim Opara, M.D., assistant professor of Internal Medicine and Pediatrics, and Latonya Riddle-Jones, M.D., M.P.H., assistant professor of Internal Medicine and Pediatrics, the taskforce includes representation from institutional leadership, students, residents, faculty, and community members and leaders, including those from the School of Medicine, Wayne Health, the Detroit Medical Center, the Barbara Ann Karmanos Cancer Institute, the Detroit Health Department and the Michigan State Medical Society.

"Race-based medicine is the practice of medicine and other forms of health care grounded in racial essentialism, which is the false belief that races are biologically distinct groups determined by genes," Dr. Opara said. "It is a key component of structural and systemic racism in medicine and has perpetuated multiple generations of harm to Black, as well as other minoritized and structurally excluded communities."

The group has delineated three primary goals to accomplish within its two-year mission:

Discontinue and de-adopt race-based medicine, including "race correction" in practice, teaching and research.

Lead the adoption and institutionalization of racism-conscious medicine in practice, education, policy and research, and provide support for clinicians and health care workers.

Organize stakeholder community roundtables and symposia on ending race-based medicine.

The taskforce is supported by Dean Wael Sakr, M.D.; the Michigan State Medical Society Taskforce to Advance Health Equity; the School of Medicines Office of Inclusion, Diversity, Equity and Access; the Health Equity and Justice in Medicine initiative at the School of Medicine and the Detroit Medical Center; and the WSU Department of Internal Medicine.

The work of this taskforce is critical to health care in our city, our state and our nation, and lives in the very soul of our Wayne State University School of Medicine and our mission, Dean Sakr said. The promise of equitable health care for all people is deeply embedded in the mission and values of the university and its health science schools. We need to lead the way in this effort.

The task force, Dr. Opara said, will consider its work successful by the measurement of several factors, including:

Removal of racialized reporting from electronic health records in areas such as Glomerular Filtration Rate, or eGFR, a test in renal function.

The discontinuation of the "race corrective" function of pulmonary function tests.

The discontinuation of inputting race as a risk factor in the atherosclerotic cardiovascular disease calculator.

The discontinuation of relying upon race as a reason for offering different medical treatments.

We will conduct regular practice and teaching audits to track the frequency of practice and teaching of these domains of race-based medicine, and when we are at zero, we will know our mission is completed, Dr. Opara said.

One impetus for the taskforce lies in the publication of a paper calling for the end of race-based medicine.

In 2021, Dr. Opara, Dr. Riddle Jones and Nakia Allen, M.D., FAAP, clinical associate professor of Pediatrics, published an article in which they called upon the medical and scientific communities to confront and end a legacy of scientific racism in research, medical education, clinical practice and health policies by de-pathologizing and humanizing American Black bodies.

In Modern Day Drapetomania: Calling Out Scientific Racism,published in the Journal of General Medicine, the physicians noted that racism in medicine has deep historical roots in white supremacy and anti-Blackness, particularly the pathologizing of Black bodies through pseudoscientific claims of the biological significance of the sociopolitical construct that is race, which is often incorrectly conflated with genetic ancestry. Those roots, they wrote, developed branches that continue to reach into medical science and medicine to this day, particularly in the ways science frames racial health disparities as a result of biological differences among racial categories.

Racism, not race, is the vector of disease and health disparities. Racist policies, such as redlining and the war on drugs and war on crime, inform systems of housing, education, criminal justice, health and the economy, and determine a communitys exposure to the social and environmental factors that drive health disparities through direct effects, chronic toxic stress and epigenetic mechanisms, the physicians wrote. This is the contemporary version of pathologizing Blackness and normal responses to chronic intergenerational trauma, oppression and exploitation. It reinforces the bogus theory of supposed Black inferiority. It is the modern Drapetomania.

Now recognized as pseudoscience nonsense, Drapetomania was first concocted by Dr. Samuel Cartwright in 1851 to pathologize runaway enslaved Blacks. He claimed that enslaved Blacks had inherently smaller brains and blood vessels that accounted for indolence and barbarism. His prescribed cure and prophylactic treatment for the faux condition was whipping the devil out of them. The nonsensical condition remained in some medical texts into the early 1900s, and was used along with other false claims to support racist perceptions and attitudes toward Black Americans. Some of those perceptions continue in medicine, despite the fact that in 2003 the Human Genome Project showed race has no genetic basis and human beings are 99.9% identical genetically.

The belief that differences in disease outcomes are due to genetic differences between racialized groups still plagues contemporary medicine and science, and unfortunately continues to be funded, published, taught and practiced, they state. The use of race to measure human biological differences stubbornly persists and, consequently, these structures and systems are absolved of responsibility, reinforced and perpetuated.

To eliminate scientific racism, the physicians called for identifying and excising it from clinical algorithms and medical decision-making equations; expunging it from the publication process through anti-racist peer review and editorship; transforming medical, health care professions, and scientific education in both clinical and social sciences from undergraduate studies through faculty development and curricular revision; and advocacy among academic partnerships with patients, marginalized communities and policymakers that prioritize social and structural determinants of health to positively impact health outcomes.

Our oath as clinicians is to first do no harm, Dr. Riddle-Jones said. When we practice race-based medicine, knowingly or unknowingly, we are performing harm on our beloved patients and communities. The time to end race-based medicine is past due. The time is now.

A number of national and international regulatory agencies, including the National Institutes of Health, the U.S. Centers for Disease Control and Prevention, the Accreditation Council for Graduate Medical Education, the Association of American Medical Colleges, the American Medical Association, the National Kidney Foundation and the American Academy of Pediatrics have called for an end to race-based medical practices and many have published updated guidelines reflecting this change. More importantly, Dr. Opara said, medical students, trainees, patients and communities are demanding this change.

Many clinicians are already on board for the change, she added. They just need support and guidance to de-adopt these established practices and adopt better ones.

Dr. Opara said that it is important to note that the taskforce is not advocating for color-blind medicine or science as there are notable differences in health outcomes among racialized groups. Instead, we are advocating for critical racism-conscious medicine, science, research, policy, education and practice that understands that the reason and context for those differences are as a result of racism and other inequitable and unjust systemic/structural factors and not as a result of mythical inherent biological differences. Research that appropriately categorizes populations and explains the basis of population categorization and how they account for racialized differences decoupled from biology is what is called for. Eliminating iatrogenic (health care-induced) disparities in order to actualize health equity is what is urgently called for.

For more information, contact Dr. Opara at innodim@wayne.edu or Dr. Riddle-Jones at lriddle@med.wayne.edu. A presentation on the task force is available at https://www.youtube.com/live/G8QYtRhlZAM?feature=share

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Taskforce works to end racialized differences in medical education and practice - Wayne State University

Internal Medicine

Against Physician-Assisted Suicide: A Physicians Letter to His Legislator – Word on Fire

Home Articles Against Physician-Assisted Suicide: A Physicians Letter to His Legislator

The committee hearings begin today, January 25, 2024, on the End-of-Life Option Act (SF 1813/HF 1930). If passed, this bill would allow residents in Minnesota access to physician-assisted suicides.

To whom it may concern:

My name is Tod Worner, and I am a practicing internal medicine physician in the Minneapolis area. I live in Plymouth, MN, and vote in District 43A. I am opposed to the proposed bill legalizing physician-assisted suicide.

I find myself in a curious position. As a physician who has spent decades trying to heal patients, I find myself imploring my duly elected representatives not to usher in the most seismic cultural and ethical transformation in modern medical practicethe act of taking life instead of comforting or saving it.

As you know, there are currently ten states (to date) in which physician-assisted suicide is legalized (California, Colorado, Oregon, Vermont, New Mexico, Maine, New Jersey, New Mexico, Hawaii, and Washington) and Washington, D.C. Montana has legalized it by court ruling. Furthermore, a number of them have weakened residency requirements so as to encourage a grim form of medical suicide tourism. Physician-assisted suicide is also legalized (to date) in Canada, Belgium, Luxembourg, Spain, Germany, Switzerland, and the Netherlands. Pediatric euthanasia has already been carried out in Belgium, the Netherlands, and is being pursued by interest groups and legislators in Canada, among other locales. And now, alas, physician-assisted suicide is, once again, knocking on Minnesotas door.

What are we becoming? What does it mean to heal?

Lest we find ourselves reassured by a burgeoning tendency to legalize this dark practice, let me borrow from Mark Twain when he said, Whenever you find yourself on the side of the majority, it is time to pause and reflect.

Indeed.

George Orwell once sighed, We have now sunk to a depth at which restatement of the obvious is the first duty of intelligent men.

And so let me begin.

As a physician,mydaily practice is to heal the sick and prevent disease. In so doing, I try to uphold thedignity of eachpatienttreating them with respect while working in partnership to achieve a rich quality in concertwith a reasonable quantity of life. Of course, I recognizethe value of autonomy to afford patient choice, but that means a choice insofar as it simultaneously comports with the practice of safe, sound, and ethical medicine. To be sure, patient choice must be just and the care they receive beneficent, but that same choice must notby slippery euphemism and crafty manipulation, emotional appeal and legal maneuveringsI repeat, must not compel a physician to commit a maleficent act, especially one that runs against centuries of common law and customs, statutory law and social contract, as well as the sacred conscience and sound judgment of the physician in the relationship.

So what does this mean when it comes to physician-assisted suicide?

In a few words, it means that a patient has many rights, but he does not have the right to demand that I assist him in killing himselfany more than he can demand I prescribe himunnecessary narcotics, unwarranted antibiotics, or ill-considered surgery. To demand these measures indiscriminately would be to violate the dignity of the patient with risky (or fatal) outcomes as well as compromise my dignity (and conscience) as a trained and seasoned physician to thoughtfully consider the best care for the patient.

That is why, as a physician, I am opposed to physician-assisted suicide. Furthermore, allow me to offer these threearguments against this concerning practice:

When Julius Caesar illegally ledhis army into Italy in defiance of the Roman Senate, he had topass through a river known as the Rubicon, which separatedItaly from the province of Gaul. When he crossed the Rubicon and became a traitor to his state, he uttered the die is cast and knew there was no going back. Once medicine has transformed itself from a vocation whose first and only priority is to heal and comfort into a profession that is willing to kill, we will have crossed the Rubicon. We will have wandered away from the oath to First, do no harm and to give no deadly medicine to any one if asked, nor suggest any such counsel. Henceforth, the consequences would be both unintended and grave to patients, physicians, and society. We must stop, once again, and reconsider just what it means to be physicians, to be healers. And we must remember what it means to be human. If we forget the fundamental, uncompromising, and ineradicable value intrinsic to human life, can we still call ourselves physicians?

The popular press, judicial activists, and enterprising legislators have grown increasingly sympathetic to the physician-assisted suicide movement. As such, anecdote after anecdote highlight people with grave medical maladies offering poignant interviews or writing last letters articulating their sincere fears of unremitting pain and incomparable suffering. They see only two alternatives: one is to suffer a prolonged, painful, and humiliating death, while the other is to proactively commit dignified suicide under the sympathetic eyes of their physician. Thats it. What is striking, however, is how little conversation there is about Palliative Care and Hospice.

Designed fully around the notion of providing dignity, autonomy, and symptom management in the face of terminal illness, Palliative Care and Hospice provide extraordinary end-of-life care to the very people who feel they have no fate but suffering ahead. These physicians and clinicians are well-trained and deeply committed to the care of those very patients that physician-assisted suicide advocates specifically target. In over two decades of practicing internal medicine, I have had a number of patients enroll in these services. I have yet to find one family who didnt gratefully describe the profound dignity, loving kindness, and tender management of pain, anxiety, and symptoms they witnessed in the waning days of their loved ones life. Surely, that is not to say that there cant be patients with symptoms that could be difficult to manage. But does that mean that we should then move to a widespread, systemic legalization of physician-assisted killing? With the oft untapped and unrecognized virtues of Palliative Care and Hospice, I think we are rushing to providea dangerous solution desperately in search of a problem.

Invariably, when legislation such as physician-assisted suicide is considered, concerns are raised about the slippery slopethat is, the unintended consequences and abuses that result from permitting such a policy at all. Enlightened minds that know better shake their heads and tut-tut that our concernsare overreactions. We would have safeguards against abuses, we are told, We would craft laws protecting minors or the mentally ill or the demented or the handicapped or others without terminal illness from ever being considered for physician-assisted suicide. It would be a rare event. Economics (a patients draining resources, the burden on the medical system) would never be a factor in a merciful act devoted to preserving the dignity of the individual.

2024 Lenten Gospel Reflections

To be sure, all of these reassuring arguments sound good and have been made in countries and states that have legalized physician-assisted suicide. And, too often, they have been wrong. People with mental illness and no terminal disease have been allowed to die. Minors in Belgium and the Netherlands have died under this policy. Physicians have been more aggressive in utilizing this option in the ill, but not terminally ill. Patients have reported fear of being hospitalized lest they become victims to a crusading doctors zeal. Exploding costs for end-of-life care and budgets groaning under the weight of the perpetually ill have a conscious or unconscious impact on a system where physician-assisted suicide is an option.

As far as being rare, according to the BMJs Journal of Medical Ethics (10/27/2023), there was an over sixteen-fold increase in physician-assisted suicide cases in Oregon from 1997 to 2022 while there was a drop in coinciding psychiatric assessments (evaluating the patients emotional state for such a decision) from 31.1% to 1.1%. The author of the paper, David Albert Jones, concludes, We now have twenty-five years of data from Oregon and data from an increasing number of other states with similar laws. However, the more we know, the less reassuring the Oregon model of assisted suicide seems to be. Nonetheless, those promoting this law will reassure us. Weve thought of these concerns and, if need be, we will enact further laws to protect patients from abuse. To this reasoning, I would ask, How will the small laws protect us, when the big law (against physician-assisted suicide) has been able to fall? When it comes to the institutionalization of physician-assisted suicide, mark my words, telling us that everything will be okay is a misguided, if not dangerous, philosophy.

For the last twenty-four years, it has been an honor and privilege to practice internal medicine. I love my patients, enjoy my colleagues, and cherish my calling. But that calling will fundamentally change if we devolve from a vocation that heals to a vocation that kills.

Most of what I have written today in opposition to physician-assisted suicide is fairly obvious. And I am here, simply and sadly, to restate it.

In having to do so, it is hard not to ask,What are we becoming? What does it mean to heal?

Heaven help us if we dont know the answer.

Thank you for your time and consideration.

Tod Worner, MD

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Against Physician-Assisted Suicide: A Physicians Letter to His Legislator - Word on Fire

Emergency Medicine

EMTALA and abortions: An explainer and research roundup – Journalist’s Resource

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For nearly four decades now, a federal law known as the Emergency Medical Treatment and Labor Act, or EMTALA, has given Americans the right to receive care at emergency departments, regardless of income or insurance status. The law applies to all kinds of emergencies, including pregnant people in labor, or those for whom an abortion may be medically necessary to preserve their health or save their life.

Since the U.S. Supreme Court struck down the constitutional right to abortion in June 2022, some experts have worried that EMTALA would clash with states that restrict or ban abortions. So far, two states Texas and Idaho have ongoing lawsuits with the federal government, claiming their state bans and restrictions on abortion take precedence over EMTALA. And on January 5, the Supreme Court said it would consider Idahos case, which centers on the relationship between EMTALA and the states abortion ban.

Legal experts worry that if the Supreme Court rules in favor of Idaho and allows states to shape their own laws for pregnancy emergencies without regard to EMTALA, then the states could apply the same logic to all other forms of emergency medical care that currently covered under the federal emergency law.

So, states could start carving out HIV care, or mental health, or serious and chronic conditions that they deem too futile or not worth the time and energy of emergency department, says Sara Rosenbaum, a professor emerita of health law and policy at George Washington Universitys Milken Institute School of Public Health, who has written extensively about EMTALA.

Through memoranda and various efforts, federal health officials have emphasized that EMTALA takes priority over state laws.

Most recently, on January 22, the 51st anniversary of Roe v. Wade, the Department of Health and Human Services and the Centers for Medicare & Medicaid Services introduced new resources for the public and health providers to learn about their rights to receive emergency medical care under EMTALA. The announcement was part of a wider effort by the White House to strengthen Americans access to contraception, medication abortion and emergency medical care.

The Department of Health & Human Services has issued other notices about the application of EMTALA, including a memorandum in September 2021 after a Texas abortion ban case, in July 2022 after the overturning of Roe and following an executive order by President Joe Biden, and in May 2023 following the investigation of two hospitals in Missouri and Kansas that violated EMTALA.

If a physician believes that a pregnant patient presenting at an emergency department is experiencing an emergency medical condition as defined by EMTALA and that abortion is the stabilizing treatment necessary to resolve that condition, the physician must provide that treatment, states a Biden administration memorandum in July 2022. When a state law prohibits abortion and does not include an exception for the life of the pregnant person or draws the exception more narrowly than EMTALAs emergency medical condition definition that state law is preempted, by the federal law.

Abortion rights advocates have filed lawsuits over several states strict abortion bans, Axios reported in September. Rosenbaum said shes preparing an amicus brief on behalf of the American Public Health Association and more than 100 law and policy scholars before the Supreme Court makes its decision on Idahos case.

EMTALA was introduced in 1985 with bipartisan support in response to a spate of patient dumping cases, which refers to emergency departments refusing care to patients who are indigent and have no health insurance, including patients who were in labor. President Ronald Reagan signed it into law in 1986, when Roe v. Wade was still law of the land.

Under EMTALA, hospitals must examine and stabilize patients, regardless of insurance status, citizenship or other factors.

It essentially is the closest thing we have in this country to a human rights statute, says Rosenbaum.

The law applies to all hospitals with emergency departments that participate in Medicare (only about 1% of non-federal community hospitals dont participate in Medicare, according to the American Hospital Association). The Department of Health and Human Services oversees and enforces EMTALA.

Physicians and hospitals can be fined up to $50,000 per incident of failing to comply with EMTALA and are at risk of exclusion from Medicare and Medicaid programs for repeated violations. Physicians malpractice insurance does not cover EMTALA violations.

While EMTALA is an important safety net for people without health insurance, it doesnt guarantee free care, and patients may still be billed, as the authors of a 2018 study published in AIMS Public Health explain.

EMTALA covers not only conditions that threaten life but also conditions that can impose severe and long-lasting health impacts. That includes pregnancy-related complications and emergencies that may require medically necessary and life-saving abortions, even though abortion is not specifically mentioned in the law.

The majority of people who have emergencies related to pregnancy go to an emergency department, according to a 2023 study published in the American Journal of Emergency Medicine. At least a third of pregnant women go to an emergency department at some point during their pregnancy, studies have shown and up to 15% suffer from a potentially life-threatening condition during the first trimester.

A 2020 study of 2.8 million women in Ontario, Canada, who were pregnant between 2002 and 2017, finds that 40% visited an emergency department, mostly during the first trimester or soon after giving birth.

The most common conditions during the first trimester were threatened abortion (the technical term for vaginal bleeding at less than 20 weeks of gestation), hemorrhage (severe bleeding), and spontaneous abortion (miscarriage), according to the study.

Other emergency medical conditions involving pregnant patients may include but are not limited to ectopic pregnancy which is when a fertilized egg grows outside of the uterus and can be a life-threatening emergency, complications of pregnancy loss, or high blood pressure conditions such as severe preeclampsia.

Dr. Glenn Goodwin, an emergency physician in Florida, says at every shift theres a first-trimester pregnant patient whos bleeding.

Id say probably 10% of our ER visits are somewhat OB-related, whether its a first-trimester bleed, or whether its abdominal pain in pregnancy, Goodwin says. How many of those cases are actually life-threatening? Very, very few.

Since the end of Roe in June 2022, 14 states have enacted a total ban on abortion, four states ban abortion after six or 12 weeks, and seven after 15 or 22 weeks. Abortion is legal, including beyond 22 weeks, in 25 states and the District of Columbia, according to the KFF, a nonpartisan health policy research organization.

What leads to confusion among health providers is the vague language of the law in states that have abortion bans.

For instance, many states with strict abortion bans have exceptions to prevent the death or preserve the life of the pregnant person, according to an analysis by KFF.

Arkansas, Idaho, Mississippi, Oklahoma and South Dakota have exceptions to save the life of the pregnant person, but do not have any exceptions for protecting their health.

Other states with abortion bans have exceptions that consider protecting the health of the pregnant person not just their life permitting abortion care when theres a serious risk of substantial and irreversible impairment of a major bodily function. The Texas abortion ban says physicians must determine whether an abortion is necessary based on their reasonable medical judgment.

These exceptions are not clear how much risk of death or how close to death a pregnant patient may need to be for theexception to apply, and the determination is not explicitly up to the physician treating the pregnant patient, according to the KFF analysis.

A KFF 2023 National OBGYN survey, including 569 physicians, finds more than half of those who practiced in states that banned abortion were concerned about their legal risk when deciding on the necessity of abortions.

In an opinion piece published in the Annals of Internal Medicine in January 2023, Dr. Eli Y. Adashi and I. Glenn Cohen write, physicians in restrictive states face extremely difficult choices between protecting pregnant persons and the threat of legal sanctions.

Out of frustration with confusion in his own emergency department, Goodwin, the Florida emergency physician, set out to do a study in 2022 on state abortion laws and whether they conflicted with EMTALA.

He and his co-authors find that the overturning of Roe does not prohibit termination of pregnancy in the setting of life-threatening conditions to the mother, including ectopic pregnancy, preeclampsia, and others, but they recommend that physicians be mindful of the rapidly-evolving laws in their particular state, and to also practice in accordance with Emergency Medical Treatment and Active Labor Act (EMTALA). Patient safety must be prioritized.

Goodwin completed his study before the Supreme Court said that it will consider whether EMTALA takes priority over Idahos restrictive abortion ban. The oral arguments are scheduled for April.

Before states like Florida passed a 15-week abortion ban except for saving the patients life, things were much clearer for emergency physicians like Goodwin.

We never really considered any legal ramification at all, Goodwin says. The patient came in and all of our brains were just focused on the medical aspect of care. Since this law change, we have to consider some of the legal aspects of it.

He gave the example of a patient whos 15 weeks pregnant, has been bleeding for days and is miscarrying, but still has a fetus with a heartbeat.

At that point, the conventional medical treatment will be to just give an abortive medication, because theres really no chance of this fetus living and the mother is bleeding, he says. And you dont want her to continue bleeding because that would be a risk.

But Floridas 15-week abortion ban makes the decision complicated. For Goodwin, whose hospital doesnt have a labor and delivery unit, the solution would have been to transfer the patient to another hospital that has a labor and delivery unit, instead of proceeding with the standard treatment in his own emergency room.

Goodwin also worries that the ongoing legal battles will further reduce the number of medical students who will choose to specialize in Ob/Gyn.

You have Ob/Gyn hopefuls saying they dont want to train in states like Mississippi because theyre not going to learn how to do an abortion, Goodwin says. And however you feel about abortion, it is kind of a crucial aspect of Ob/Gyn training because there are times where you have to do it as a life-saving procedure.

An April 2023 report by the Association of American Medical Colleges shows that the number of applicants for Ob/Gyn residencies dropped in all states in 2023, but had the steepest decline in states with abortion bans. In those states, applications dropped by 10.5% compared with the previous year.

To help journalists prepare to cover the upcoming Supreme Court hearing, weve gathered several research studies on EMTALA, including analyses of hospitals general compliance issues since the law was passed. The studies were published both before and after the overturning of Roe.

A National Analysis of ED Presentations for Early Pregnancy and Complications: Implications for Post-Roe America Glenn Goodwin, et al. The American Journal of Emergency Medicine, August 2023.

The study: The study, published before the Supreme Court took up EMTALA, uses data from the National Hospital Ambulatory Medical Care Survey, from 2016 to 2020, to evaluate trends in pregnancy-related emergency department visits that could be impacted by restrictive abortion laws. The dataset included 4,556,778 pregnancy-related emergency department visits in the U.S. The authors also analyzed the state laws.

The findings: Nearly 80% of the visits in the study were for patients between 18 to 34 years old. This age group also made up 76% of visits for pregnancy complications, including ectopic pregnancies, and 80% of visits for miscarriage or threat of miscarriage in early pregnancy. This age group also accounted for all visits for complications following an induced abortion or a failed abortion.

A quarter of the patients were Black and 70% were white. By ethnicity, 27% of the patients were Hispanic.

Almost 71% of the visits were due to complications after an induced abortion occurred in patients who lived in the South. Such visits were also twice as likely to occur in non-metro areas.

Nearly 50% of the patients were covered by Medicaid, compared with about 25% with private insurance. About 10% had no insurance.

The takeaway: Pregnancy-related emergency department visits comprise a significant proportion of emergency care, the authors write. The overturning of Roe does notprohibittermination of pregnancy in the setting of life-threatening conditions to the mother, including ectopic pregnancy,preeclampsia, and others, but the resultant uncertainty and ambiguity surrounding the constitutional change is leading to an over-compliance of the law, necessarily obstructingreproductive healthcare, they write.

Penalties for Emergency Medical Treatment and Labor Act Violations Involving Obstetrical Emergencies Sophie Terp, et al. The Western Journal of Emergency Medicine, March 2020.

The study: Theres no question that EMTALA applies to active labor, which is the only medical condition labor included in the title of the law, the authors write. They review descriptions of EMTALA violation settlements involving labor and other obstetric emergencies, listed on the Office of the Inspector General website between 2002 and 2018.

The findings: Of 232 EMTALA violation settlements, 17% (39) involved active labor and other obstetric emergencies. Settlements involving obstetric emergencies increased from 17% to 40% during the study period. Of those, 18% involved a pregnant minor. Most violations involved failure to screen and/or stabilize the pregnant patient.

Of the 39 cases, the Southeast had the most number of violations 38%, including eight violations in Florida and five in North Carolina.

The takeaway: Recent cases highlight the need for hospital administrators, emergency physicians, and obstetricians to evaluate and strengthen policies and procedures related to both screening exams and stabilizing care of patients with labor and OB emergencies, even if the hospital does not provide dedicated OB care, the authors write.

Complying With the Emergency Medical Treatment and Labor Act (EMTALA): Challenges and Solutions Charleen Hsuan, et al. Journal of Healthcare Risk Management, November 2017.

The study: Despite the passage of EMTALA in 1986, hospitals continue to violate it, which includes refusing to examine or stabilize patients, or making inappropriate transfers to other hospitals. In the first decade after the law was passed, nearly one-third of U.S. hospitals were investigated for EMTALA violations. And as of 2011, almost 30 years after the Act was passed, 40% of investigations still found violations, they write.

The authors explore the reasons for not complying with EMTALA and suggest ways to improve compliance. Their analysis is based on 11 interviews with hospital officials, hospital associations and patient safety organizations that review clinical data on EMTALA violations in Georgia, Kentucky, North Carolina, South Carolina and Tennessee. The South had the highest number of EMTALA complaints at the time, compared with other U.S. regions.

The findings: There were five main reasons for non-compliance: financial incentives to avoid unprofitable patients; ignorance of EMTALAs requirements; high burned of referral at hospitals that receive EMTALA transfer patients; reluctance to jeopardize relationships with transfer partners by reporting borderline EMTALA violations; and opposing priorities of hospitals and physicians.

The authors propose four ways to improve compliance with EMTALA: align federal and state payment policies with EMTALA; amend EMTALA to permit informal mediation sessions between hospitals to address borderline EMTALA violations; increase the hospital role in EMTALA training and spread information; and increase the role of hospital associations.

Emergency Medical Treatment and Labor Act (EMTALA) 2002-15: Review of Office of Inspector General Patient Dumping Settlements Nadia Zuabi, Larry D. Weiss, and Mark I. Langdorf. The Western Journal of Emergency Medicine, May 2016.

The study: The Office of Inspector General (OIG) of the Department of Health and Human Services enforces EMTALA. The study examines the scope, cost, frequency and common allegations leading to mandatory settlements against hospitals and physicians for patient dumping. The enforcement actions are listed on the OIG website, where you can find more recent cases.

The findings: Between 2002 and 2015, there were 192 settlements, with fines adding up to $6.4 million. The average fine against hospitals was $33,435 and against physicians was $25,625. 96% of the fines were against hospitals.

The most common settlements were for failing to screen the patient or stabilize them in emergency situations. There were 22 cases of inappropriate transfer to another hospital and another 22 cases for failing to transfer to a facility that could care for the patient. In 25 cases, hospitals failed to accept an appropriate transfer. In 30 cases hospitals turned away patients because their insurance or financial status. Thirteen cases involved a patient in active labor.

Examining EMTALA in the Era of the Patient Protection and Affordable Care Act Ryan M. McKenna, et al. ASIM Public Health, October 2018.

The study: The authors examine the characteristics of hospitals that violated EMTALA between 2002 and 2015 before and after the implementation of ACA in 2014 using the OIG database and matching them with a national hospital database.

The findings: There were 191 EMTALA settlement agreements during the study period, although the analysis included 167 cases after excluding others due to lack of data. Settlements decreased from a high of 46 in 2002 to a low of six in 2015, a decline of 87%. The settlements were most common in hospitals in the South (48%) and urban areas (74%). The average settlement for hospitals was $31,734, adding up to $5,299,500 during the study period.

The takeaway: There was an overall downward trend in violations of EMTALA, even though the study cant establish that the implementation of ACA caused the downward trend. The authors suggest the reduction in EMTALA violations could be due to two factors: First, in shifting hospitals payer mix away from self-pay, the insurance expansion of the ACA reduces the risk of uncompensated care to systems, they write. Second, the ACA helped improve access to health care at facilities other than the ED.

Will EMTALA Be There for People with Pregnancy-Related Emergencies? Sara Rosenbaum, Alexander Somodevilla and Maria Casoni. The New England Journal of Medicine, September 2022.

The Enduring Role Of The Emergency Medical Treatment And Active Labor Act Sara Rosenbaum. Health Affairs, December 2013.

Emergency Medical Treatment and Labor Act: Impact on Health Care, Nursing, Quality, and Safety Theresa Ryan Schultz, Jacqueline Forbes, and Ashley Hafen Packard. Quality Management in Health Care, March 2024.

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EMTALA and abortions: An explainer and research roundup - Journalist's Resource

Emergency Medicine

Study: AI Surveillance Tool Successfully Helps to Predict Sepsis, Saves Lives – UC San Diego Health

Each year, at least 1.7 million adults in the United States develop sepsis, and approximately 350,000 will die from the serious blood infection that can trigger a life-threatening chain reaction throughout the entire body.

In a new study, published in the January 23, 2024 online edition of npj Digital Medicine, researchers at University of California San Diego School of Medicine utilized an artificial intelligence (AI) model in the emergency departments at UC San Diego Health in order to quickly identify patients at risk for sepsis infection.

The study found the AI algorithm, entitled COMPOSER, which was previously developed by the research team, resulted in a 17% reduction in mortality.

Our COMPOSER model uses real-time data in order to predict sepsis before obvious clinical manifestations, said study co-author Gabriel Wardi, MD, chief of the Division of Critical Care in the Department of Emergency Medicine at UC San Diego School of Medicine. It works silently and safely behind the scenes, continuously surveilling every patient for signs of possible sepsis.

Once a patient checks in at the emergency department, the algorithm begins to continuously monitor more than 150 different patient variables that could be linked to sepsis, such as lab results, vital signs, current medications, demographics and medical history.

Should a patient present with multiple variables, resulting in high risk for sepsis infection, the AI algorithm will notify nursing staff via the hospitals electronic health record. The nursing team will then review with the physician and determine appropriate treatment plans.

These advanced AI algorithms can detect patterns that are not initially obvious to the human eye, said study co-author Shamim Nemati, PhD, associate professor of biomedical informatics and director of predictive analytics at UC San Diego School of Medicine. The system can look at these risk factors and come up with a highly accurate prediction of sepsis. Conversely, if the risk patterns can be explained by other conditions with higher confidence, then no alerts will be sent.

The study examined more than 6,000 patient admissions before and after COMPOSER was deployed in the emergency departments at UC San Diego Medical Center in Hillcrest and at Jacobs Medical Center in La Jolla.

It is the first study to report improvement in patient outcomes by utilizing an AI deep-learning model, which is a model that uses artificial neural networks as a check and balance in order to safely, and correctly, identify health concerns in patients. The model is able to identify complex and multiple risk factors, which are then reviewed by the health care team for confirmation.

It is because of this AI model that our teams can provide life-saving therapy for patients quicker, said Wardi, emergency medicine and critical care physician at UC San Diego Health.

COMPOSER was activated in December 2022 and is now also being utilized in many hospital in-patient units throughout UC San Diego Health. It will soon be activated at the health systems newest location, UC San Diego Health East Campus.

UC San Diego Health, the regions only academic medical system, is a pioneer in the field of AI health care, with a recent announcement of its inaugural chief health AI officer and opening of the Joan and Irwin Jacobs Center for Health Innovation at UC San Diego Health, which seeks to develop sophisticated and advanced solutions in health care.

Additionally, the health system recently launched a pilot in which Epic, a cloud-based electronic health record system, and Microsofts generative AI integration automatically drafts more compassionate message responses through ChatGPT, alleviating this additional step from doctors and caregivers so they can focus on patient care.

Integration of AI technology in the electronic health record is helping to deliver on the promise of digital health, and UC San Diego Health has been a leader in this space to ensure AI-powered solutions support high reliability in patient safety and quality health care, said study co-author Christopher Longhurst, MD, executive director of the Jacobs Center for Health Innovation, and chief medical officer and chief digital officer at UC San Diego Health.

Co-authors of this study include Aaron Boussina, Theodore Chan, Allison Donahue, Robert El-Kareh, Atul Malhotra, Robert Owens, Kimberly Quintero and Supreeth Shashikumar, all at UC San Diego.

The study was funded, in part, by the National Institutes of Health (grants K23GM146092, R01LM013998, R42AI177108 and R35GM143121), the National Library of Medicine (grant 2T15LM011271-11), and the Joan and Irwin Jacobs Center for Health Innovation at UC San Diego Health.

Disclosure: Study co-authors Shamim Nemati, Aaron Boussina, Supreeth Shashikumar and Atul Malhotra are co-founders of a UC San Diego start-up, Healcisio Inc., which is focused on commercialization of advanced analytical decision support tools, and formed in compliance with UC San Diego conflict of interest policies.

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Study: AI Surveillance Tool Successfully Helps to Predict Sepsis, Saves Lives - UC San Diego Health

Emergency Medicine

Race and ethnicity may affect whether and where hospitals transfer patients – Pennsylvania State University

The researchers analyzed six models, each of which explored specific aspects of how hospital transfers relate to a variety of factors, including patient race and ethnicity, patient insurance status, patient medical conditions, referring hospital urbanicity or rurality, and the market of hospitals around the referring hospital.

According to Hsuan, every model was important because each of these factors can affect whether and where a hospital transfers a patient. A rural hospital may be more likely to transfer a patient to a better-equipped regional hub hospital, public or not. A patient with Medicaid may be transferred differently than a patient with private insurance, and both may be transferred differently than a patient with no insurance.

The researchers compared the hospital transfer rates of non-Hispanic Black patients, Hispanic patients and non-Hispanic white patients. Results for Hispanic patients varied based on the specific conditions of the transfer, but Black patients were consistently transferred to public hospitals more often than white patients across all six models. The only times Black patients were not transferred more than white patients were a few specific medical conditions like strokes and heart attacks for which rigorous transfer protocols exist.

The disparity in the transfer rates varied based on which factors were being considered. Overall, 16.6% of Black patients were transferred to a public hospital while only 11.5% of white patients were. Health care system factors like hospital market and urbanicity accounted for most of the disparity. However, when comparing Black and white patients from the same hospital with similar health conditions and the same insurance, there was still an 0.8 percentage point difference in the rate of transfers to public hospitals resulting in more Black patients being transferred than white patients.

No matter how similar the hospitals or patients were that we compared, a difference between transfer rates to public hospitals for Black and white patients persisted, Hsuan said. Even a small percentage difference affects many, many people when your system has millions of transfers.

The researchers described the racial disparity as concerning in their publication. Hsuan said the reason for the disparity needs to be investigated, but addressing the problem is more important than immediately understanding the root cause.

Our data do not allow us to identify why Black people are transferred to public hospitals more often, but whatever the cause, there is inequality in the system that should be examined and corrected, Hsuan said. We need to address this inequality so that a person of any background can enter any emergency department and receive the best possible care to treat their condition and if needed potentially save their life.

Co-authors of this research include David Vanness, Department of Health Policy and Administration at Penn State; Yinan Wang, Department of Health Policy and Administration at Penn State; Douglas Leslie, Department of Public Health Sciences at Penn State; Eleanor Dunham, Department of Emergency Medicine at Penn State; Jeannette Rogowski, Department of Health Policy and Administration at Penn State; Alexis Zebrowski, Department of Emergency Medicine and Department of Population Health Science and Policy at Icahn School of Medicine at Mount Sinai; Brendan Carr, Department of Emergency Medicine and Department of Population Health Science and Policy at Icahn School of Medicine at Mount Sinai; David Buckler, Department of Emergency Medicine at Icahn School of Medicine at Mount Sinai; and Edward Norton, Department of Health Management and Policy and Department of Economics at University of Michigan.

The National Institute on Minority Health and Health Disparities, the Penn State Clinical and Translational Science Institute and the Penn State Social Science Research Institute supported this research.

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Race and ethnicity may affect whether and where hospitals transfer patients - Pennsylvania State University

Emergency Medicine

Opinion: To reduce ER wait times, hospitals must stop using them as in-patient warehouses – The Globe and Mail

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Ambulances sit at the emergency room entrance at the Michael Garron Hospital, in Toronto, on April 29, 2021.Frank Gunn/The Canadian Press

James Worrall and Paul Pageau are emergency physicians at the Ottawa Hospital. Dr. Pageau is also a former president of the Canadian Association of Emergency Physicians.

Wait times for emergency department (ED) care have ballooned across Canada. At the ED where we work, patients who arrive in the evening are routinely not seen by a doctor until after 8 oclock the following morning. As we move through the winter, with continued high levels of respiratory illness, we will likely see the situation worsen.

But the standard explanations for long wait times are wrong. We repeatedly hear that there is nowhere else for patients to go because they do not have a family doctor. Patients are also often criticized for inappropriately using EDs. The scientific research, however, shows that we can blame neither the breakdown in Canadas primary care system, nor our patients, for overcrowding. It is ineffective patient-flow practices that unnecessarily increase wait times.

Research by the Canadian Institute for Health Information has shown that only 20 per cent of emergency patients who are ultimately discharged have a condition that could be managed in a family doctors office. Research also shows that these patients are the least complex and least time-consuming of all those we see in the ED. Patients with minor issues only modestly affect wait times for patients with more serious problems. So, even if they could be diverted to other clinics, overall waits and volumes are unlikely to improve.

Even patients who do have a family doctor often choose to come to the ED. Why? Studies show there are several reasons. Often, patients perceive their problem may be serious or dangerous, i.e., an emergency. Or they believe they require a test or treatment that can only happen in the ED.

Since the early days of emergency medicine, the medical establishment and politicians have derided patients for using the health care system inappropriately. This is nonsense. The great majority of ED patients are rational people who put up with terrible waits because they have real concerns that need to be addressed. Sometimes, patients think they are having a health emergency, such as a heart attack or appendicitis, but they are not. To sort that out, of course, requires a medical assessment and testing. How can we expect patients to be able to determine what is a health emergency on their own?

Demand for unscheduled care is normal. Emergencies, both major and minor, will not stop happening. Trying to solve ED wait times by diverting patients elsewhere will never make a meaningful impact. It is time to stop blaming patients and a lack of family doctors. Instead, we need to tackle the real cause of overcrowding: ED beds are filled with admitted patients.

The majority of stretchers and resources in most Canadian EDs are used to care for patients who have already been seen and treated in the ED, but who require admission to the hospital and are simply waiting for an in-patient bed. Despite regional variations in funding and patient demographics, every large hospital in Canada suffers from this malaise. It is the natural byproduct of ineffective patient-flow procedures.

All hospitals experience fluctuations in their in-patient census. The problem is that we use the ED as a buffer zone to handle this variation. In effect, it has become the waiting room for in-patient care. In-patient units also struggle to discharge patients, particularly the elderly, who need posthospitalization services such as long-term care, rehabilitation or community care. We clearly need to improve access to these services.

Leaving admitted patients in the ED in the meantime is not, however, a safe or logical solution, as it has unintended consequences. When ED stretchers are being used by patients better cared for in an in-patient unit, they are not available for new patients waiting to be seen. Holding admitted patients in the ED has been shown to increase in-hospital mortality, lengthen stays and increase costs. This evidence is ignored, because change is perceived to be too difficult. It would require hospitals to adopt dynamic staffing and operations models.

But this is possible. Britain, Australia and New Zealand have all implemented rules that ensure admitted patients are moved to in-patient units within hours. While not perfect, such rules do free up critical space in the ED, reduce wait times and may reduce mortality. ED wait times will not improve in Canada until governments have the courage to make similar rules. This will require political mettle, and hospitals will have to make difficult modernizations to their age-old patient-flow strategies.

So let us dispense with the fiction that long waits in the ED are due to patients presenting with minor problems, and that fixing primary care will solve things. People will always need emergency care, and they cannot get it if hospitals continue warehousing admitted patients in the ED.

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Opinion: To reduce ER wait times, hospitals must stop using them as in-patient warehouses - The Globe and Mail

Emergency Medicine

Physician Summits World’s Seven Highest Mountains — And You Can Join Him – Medpage Today

After a decade of expeditions around the world, Kentucky-based emergency medicine physician Ben Mattingly, MD, has finally summited the highest mountain on each continent -- a feat known as the seven summits.

While chipping away at the seven peaks, Mattingly has been simultaneously growing his business, Wild Med Adventures, which runs "adventure CME" trips around the world to train healthcare professionals on real-world situations that could happen while mountaineering, white water rafting, hunting, biking, and more.

MedPage Today caught up with Mattingly, who we last spoke with nearly a decade ago when Wild Med Adventures was just getting off the ground. Since then, thousands of physicians and other healthcare workers have gone on adventure CME trips with him, and the company's offerings have expanded; in addition to mountain-based trips, they now offer diving, off-roading, and wellness retreats -- and yes, there's still a duck hunting trip.

Mattingly's career combines medicine and adventure, yet he didn't travel much growing up in Kentucky. A year-long trip to New Zealand with his wife and kids further ignited his love for travel and adventure.

"I think I've always had sort of an adventurous spirit. And I think what you'll find is a lot of people who go into emergency medicine already have a little bit of a love for adrenaline," he said.

The Seven Summits

Mattingly also founded a Wilderness Medicine Fellowship at UMass Chan Medical School-Baystate in Massachusetts, and together with the first fellow, Joseph Schneider, MD, he ascended Mount Aconcagua in Argentina, the tallest mountain in the Americas, in 2013. That experience introduced him to an opportunity to climb Carstensz Pyramid (also called Puncak Jaya) in Indonesia, which he summited 2 years later.

After that, he and his wife, Jennifer Mattingly, PA-C, who also helps run Wild Med Adventures, led an adventure CME trip to Mount Kilimanjaro in Tanzania in 2016. Later that year, he also climbed Mount Elbrus in Russia.

Then, in 2019, Mattingly, his father, and frostbite expert Chris Imray, PhD, summited Mount Vinson in Antarctica. Mattingly had grown more confident and experienced at this point, and decided to summit Mount Denali in Alaska without a professional guide like he had on the other trips. His first attempt in 2017 had bad weather and was unsuccessful. But in 2021, alongside his father and eldest son, he reached the top of Denali.

Finally, last year, Mattingly's ascent of Mount Everest -- the tallest mountain in the world -- sealed the deal, though the experience was not without challenges. He first led a Wild Med Adventures trip to Everest's base camp and stayed to tackle his last peak. His dad was supposed to join, but got sick and had to turn back for medical care in Kathmandu. Mattingly and a Sherpa forged on through Everest's notorious foot traffic, waiting their turn and for a weather window to finally make the ascent. Making the way back down was treacherous, too; another party fell down, knocking down Mattingly and injuring his leg, which he later found out was a torn meniscus.

"If I'd had broke my leg there, it's probably game over," he thought. Luckily, he pushed through the excruciating knee pain and made it to the bottom safely, for which he said he's fortunate.

Going on Wild Med Adventures

Mattingly leads most Wild Med Adventures trips himself and said he gets a lot of repeat customers who come back from one adventure ready to embark on another. It's also fairly common for spouses to come along. Plus, he noted that many people come back from trips inspired to make changes in their life. For instance, one attendee who was actually a banker found a passion for wilderness medicine and went back to PA school.

It makes sense that someone with an emergency medicine background like Mattingly is drawn to this work, but he said the trips make all physicians more well rounded, even if the topics don't play heavily in their day-to-day practice.

For example, going on a hunting-based CME trip gives insight on patients who hunt, and how they may have increased risk for heart disease. Even for cases where a stranger needs help from a doctor, having refreshers on tourniquets or frostbite could come in handy and save someone's life.

One of the company's most popular trips is the annual trek to Kilimanjaro, where participants experience altitude sickness together and have conversations about relevant health issues along the way.

"So you're going over all of the pathophysiology of altitude -- what is high-altitude pulmonary edema? What is frostbite? How do you take care of it? How do you treat hypothermia?" Mattingly explained.

Meanwhile, diving trips focus more on topics such as decompression control, hemorrhage control, and jellyfish stings. He hopes to add trips for rock climbing and skiing to the roster in the coming years.

A more recent addition were wellness retreats at serene destinations, like a lodge in New York's Adirondack Mountains.

"Those have been really popular because I think the medical community is falling apart, to be honest," Mattingly said. "I'm seeing young guys finish residency and then only 2 years out, they look depressed and tired."

He sees small-group adventure CME trips as an invigorating alternative to the traditional CME acquisition.

Trip prices range from $1,500 for shorter trips and wellness retreats, to upwards of $10,000 for the longer trips, and the cost doesn't cover airfare. CME credits vary as well, ranging from around 10 to 20 per trip. More information is available on the Wild Med Adventures website.

Rachael Robertson is a writer on the MedPage Today enterprise and investigative team, also covering OB/GYN news. Her print, data, and audio stories have appeared in Everyday Health, Gizmodo, the Bronx Times, and multiple podcasts. Follow

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Physician Summits World's Seven Highest Mountains -- And You Can Join Him - Medpage Today

Emergency Medicine

UH opening new urgent care facility, relocating another – Bay News 9

CLEVELAND University Hospitals is opening a new urgent care facility and relocating another at the end of January, according to a press release.

The urgent cares will be a welcome addition to both communities and reduce their travel time when seeking medical attention, the release states. The new locations are part of the larger plan to deliver health care closer to where patients live, shop and work.

The facility being relocated is UH Urgent Care Streetsboro, previously located at the UH Streetsboro Health Center. It will move to 9449 State Route 14, Streetsboro, Ohio 44241 and will open on Jan. 29.

The new facility, UH Urgent Care Shaker Heights, will be located at 16601 Chagrin Blvd., Shaker Heights, Ohio 44120 and will open on Feb. 1.

These locations will be open from 8 a.m. to 8 p.m. every day, with some exceptions for holidays.

Our UH Urgent Care delivery model aims to provide the most convenient and valuable care for our patients, said Dr. Paul Hinchey, UH chief operating officer, in the release. Having easy access to urgent care locations provide a more affordable option than emergency departments for patients who dont have a primary care physician but need immediate, non-life-threating medical attention. By offering more urgent care locations, we can relieve the burden on emergency departments and reduce wait times so our emergency medicine teams can focus on critical cases.

The release notes that this expansion will add hundreds more health care jobs to the local market and that the hospital network is currently looking for medical professionals, who can click this link for more information.

Dr. Lee Resnick, UH Urgent Care president, said in the release that their goal is to remove obstacles and ease access to health care while still providing patients with good experiences.

The expansion of UH Urgent Care in Northeast Ohio is a significant step towards fulfilling this commitment, Resnick said in the release. By increasing access to urgent care services, we aim to make a positive impact on the lives of individuals and families throughout the region, providing them with the prompt and effective care they deserve in retail locations where they live, shop and work.

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UH opening new urgent care facility, relocating another - Bay News 9