Commentary

On February 21 to 24, 2016, the Association of Academic Chairs of Emergency Medicine (AACEM) held its 8th annual retreat in Tempe, Arizona. The AACEM is comprised of full, acting, interim, and emeritus chairs and directors of departments of emergency medicine (EM) who work to improve and support academic departments of EM in the advancement of health care through high-quality education and research.

During that event, AACEM President Greg Volturo, MD, organized a panel discussion of EM leaders to provide an update on their organizations’ recent activities. This panel included representatives from seven prominent EM organizations: the American Academy of Emergency Medicine (AAEM), AAEM Resident and Student Association (AAEM/RSA), American Board of Emergency Medicine (ABEM), American College of Emergency Physicians (ACEP), Council of Emergency Medicine Residency Directors (CORD), Emergency Medicine Residents’ Association (EMRA),  and Society for Academic Emergency Medicine (SAEM).

The following is the first of a two-part article that provides highlights from that discussion, with reports from the AAEM, AAEM/RSA, ABEM, and ACEP. Part 2 will appear in the May issue and will include reports from the CORD, EMRA, and SAEM.

American Academy of Emergency Medicine

Kevin G. Rodgers, MD, FAAEM, President AAEM

Due Process. AAEM highlighted the problem of the lack of due process for many emergency physicians (EPs). By agreeing to waive their rights to due process when signing contracts with some contract management companies, EPs can unwittingly give their employers the power to terminate them without cause and without notice. AAEM is working with Centers for Medicare & Medicaid Services (CMS) and several congressmen to amend the Medicare Rules for Participation to include an “unwaivable due process guarantee.” In addition, AAEM is requesting an addition to the current Code of Federal Regulation to ensure EPs are entitled “to a fair hearing and appellate review through hospital medical staff mechanisms before any termination or restriction of their professional activity or medical staff privileges. These rights cannot be denied through a third party contract.”

AAEM Residency Visitation Program. AAEM is committed to visiting every EM residency program once every 3 to 4 years, similar to the ACEP and ABEM programs. Residency programs will have the opportunity to select from a list of well-known EM speakers; they will deliver a clinically oriented lecture, followed by a presentation on AAEM. The cost of the program is borne completely by AAEM.

AAEM Physician Group (AAEM-PG). This program was announced at the 2016 AAEM Scientific Assembly. AAEM-PG establishes and supports EM practices where physicians can operate democratically and have an equal voice. It is a practice that is run by the local physicians for the physicians. AAEM-PG will help guide new as well as established EM groups, providing for physicians’ autonomy, fair and equitable practice environments, and career and group longevity.

AAEM Resident and Student Association

Victoria Weston, MD, AAEM/RSA President

Overview. Started in 2005, AAEM/RAS now has over 3,500 members and 58 EM residency programs with 100% participation. Benefits of membership include access to EM:RAP and The Journal of Emergency Medicine, access and opportunities to contribute to an RSA peer-reviewed blog and Modern Resident, and free registration for the AAEM Annual Scientific Assembly. As part of the AAEM Scientific Assembly, AAEM/RSA coordinates a day-long education track in collaboration with the AAEM Young Physician Section, an In-Training Exam review, and a Career Fair and Social.

Congressional Elective. Members of AAEM/RSA can apply to be selected for a one-month “Congressional Elective” with Congressmen Raul Ruiz and Joe Heck, the only two EPs currently in Congress, to teach EPs the process of creating health-policy legislation on Capitol Hill. For 4 weeks, residents work directly in their congressional office and learn to work with constituents to develop relevant health-policy legislation. Residents learn to present legislative briefs, proposals, and research in a productive, succinct, and time-efficient manner. AAEM/RSA also offers an annual Advocacy Day, where residents and students have the opportunity to meet with members of Congress and/or senior congressional staff on Capitol Hill; this year it will be held on June 14, 2016 in Washington, DC.

Toxicology Mobile App. The AAEM/RSA Toxicology mobile app will soon be available for purchase, and is compatible with both iPhone and Android technology. You can search by subject, browse chapters of AAEM/RSA’s Toxicology Handbook, or contact Poison Control with a single click.

American Board of Emergency Medicine

Francis L. Counselman, MD, Immediate Past President, ABEM

Enhanced Oral (eOral) Certification Examination. ABEM has completed its second eOral examination; the third is scheduled for April 2016. Three of the examination cases are now in the new eOral format, which uses a computer monitor, patient avatar, picture archiving and communication system (PACS)-quality radiographs, and dynamic rhythm strips. Feedback from test-takers and examiners has been quite positive. ABEM will be moving more cases to the eOral format in the near future.

ABEM Director of Medical Affairs. ABEM has named its first ever Director of Medical Affairs (DMA): Melissa A. Barton, MD. Dr Barton is a former EM Residency Program Director and has been an ABEM Oral Examiner for the past 10 years. She is the recipient of several teaching and leadership awards. Dr Barton will focus on clinically oriented special projects and represent ABEM’s interests to external organizations.

Emergency Medicine Subspecialties. EM now has 13 subspecialty opportunities for EPs; that’s more than double the number from just 5 years ago. Emergency Medical Services (EMS) now has the most ABEM diplomates (445), followed by Medical Toxicology (367) and Pediatric Emergency Medicine (245).

Lifelong Learning and Self-Assessment (LLSA) Test Accessibility. To provide LLSA readings that better match a diplomate’s area of practice, the EMS and Medical Toxicology LLSA readings and tests can now be used by any diplomate to fulfill his or her Maintenance of Certification (MOC) Part II requirements. Pediatric EM LLSA readings and tests will eventually be made available to all diplomates at a later date. All LLSAs can be accessed through the ABEM Web site (https://www.abem.org).

Maintenance of Certification (MOC) Adds Value. In a survey of ABEM diplomates taking the 2014 ConCert Examination, 92.5% found value in maintaining their ABEM certification. In a follow-up survey in 2015, 90.4% stated their medical knowledge was reinforced and/or increased by preparing and taking the ConCert Examination. In addition to being relevant to our diplomates’ practice, ABEM has worked hard to control MOC costs. ABEM has not increased its fees for the last 5 years for the LLSAs; for all remaining examinations, there has been no fee increase for the past 4 years. When compared to all other boards, the expense of the ABEM MOC Program is at the median, costing EPs approximately $265 per year, or about $5 each week.

American College of Emergency Physicians

Jay A. Kaplan, MD, FACEP, ACEP President

Physician Burnout. Unfortunately, EM leads all specialties in the frequency of physician burnout. Emergency physicians must be aware of burnout, and take proactive steps to avoid it. To help EPs, ACEP has organized an “Emergency Medicine Wellness Week.” Prevention tips include eating well, getting the proper amount of sleep, regular exercise, and improving the work environment. In 2016, Wellness Week ran from January 24 to 30; there is a continuing focus on building resilience and preventing compassion fatigue.

Out of Network (OON) Balance Billing. Insurance companies know that it is solely the cost of insurance premiums that consumers pay attention to, not deductibles or exactly what the insurance covers. Those same insurance companies have been adept at portraying physicians as the cause of “surprise billing.” Emergency physicians need to change the conversation from “surprise billing” to “surprise coverage.” We need to talk about fair coverage for our patients, rather than asking for fair payment for physicians (the latter will follow the former and legislators believe that physicians are already fairly paid). ACEP is considering legal action against CMS and the Center for Consumer Information and Insurance Oversight regarding their final rule on “the greatest of three,” which establishes guidelines for how physicians are to be paid for services rendered.

Pay for Performance and Value-based Reimbursement. ACEP has created a joint task force with the Emergency Department Practice Management Association to create a toolbox for EPs to navigate the changing reimbursement landscape. This includes model legislation and best practices, and there is exploration regarding developing alternative payment models for EM.

Opioid Epidemic. ACEP is a participant in the White House working group exploring this epidemic and identifying strategies to combat this national problem. ACEP has sent a letter to CMS and Health and Human Services (HHS) requesting removal of the pain questions from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. Emergency physicians should not be penalized on these surveys for not prescribing narcotic analgesics to patients who could be treated appropriately with nonnarcotic medications. ACEP similarly is considering sending a letter to The Joint Commission requesting removal of their emphasis on pain as the “fifth vital sign.”

Mass Casualty Incidents. ACEP has created a “New High-Threat High-Casualty Task Force” to identify best practice recommendations for provision of emergency care in high-threat environments and identify current clinical and operational knowledge gaps surrounding the issue. This in turn will help prioritize future ACEP research objectives based on these gaps. In addition, a white paper is being prepared, highlighting current national efforts and recommending clinical practice guidelines for adults and pediatric patients, as well as a future strategy for ACEP engagement as a national leader in the area of high-threat emergency care.

Diversity. There is a recognized need to increase the diversity in our current and future EM leadership. To that end, ACEP sponsored a Diversity Summit on April 14, 2016 in Dallas to explore these issues and make recommendations.

Emergency Quality Network. ACEP, along with 38 other health care organizations, received a grant in the CMS Transforming Clinical Practice Initiative to help physicians achieve large-scale health transformation. Areas of EM focus include: improving outcomes for patients with sepsis; reducing avoidable imaging in low-risk patients through implementation of ACEP’s Choosing Wisely campaign; and improving the value of ED chest pain evaluation in low-risk patients by reducing avoidable testing and admissions.

Editor’s Note: Part 2 of this article will appear in the May 2016 issue of Emergency Medicine and will feature reports from the Council of Emergency Medicine Residency Directors (CORD), the Emergency Medicine Residents’ Association (EMRA), and the Society for Academic Emergency Medicine (SAEM). Have a comment or question about this article? Let us know: [email protected].

On February 21 to 24, 2016, the Association of Academic Chairs of Emergency Medicine (AACEM) held its 8th annual retreat in Tempe, Arizona. The AACEM is comprised of full, acting, interim, and emeritus chairs and directors of departments of emergency medicine (EM) who work to improve and support academic departments of EM in the advancement of health care through high-quality education and research.

During that event, AACEM President Greg Volturo, MD, organized a panel discussion of EM leaders to provide an update on their organizations’ recent activities. This panel included representatives from seven prominent EM organizations: the American Academy of Emergency Medicine (AAEM), AAEM Resident and Student Association (AAEM/RSA), American Board of Emergency Medicine (ABEM), American College of Emergency Physicians (ACEP), Council of Emergency Medicine Residency Directors (CORD), Emergency Medicine Residents’ Association (EMRA),  and Society for Academic Emergency Medicine (SAEM).

The following is the first of a two-part article that provides highlights from that discussion, with reports from the AAEM, AAEM/RSA, ABEM, and ACEP. Part 2 will appear in the May issue and will include reports from the CORD, EMRA, and SAEM.

American Academy of Emergency Medicine

Kevin G. Rodgers, MD, FAAEM, President AAEM

Due Process. AAEM highlighted the problem of the lack of due process for many emergency physicians (EPs). By agreeing to waive their rights to due process when signing contracts with some contract management companies, EPs can unwittingly give their employers the power to terminate them without cause and without notice. AAEM is working with Centers for Medicare & Medicaid Services (CMS) and several congressmen to amend the Medicare Rules for Participation to include an “unwaivable due process guarantee.” In addition, AAEM is requesting an addition to the current Code of Federal Regulation to ensure EPs are entitled “to a fair hearing and appellate review through hospital medical staff mechanisms before any termination or restriction of their professional activity or medical staff privileges. These rights cannot be denied through a third party contract.”

AAEM Residency Visitation Program. AAEM is committed to visiting every EM residency program once every 3 to 4 years, similar to the ACEP and ABEM programs. Residency programs will have the opportunity to select from a list of well-known EM speakers; they will deliver a clinically oriented lecture, followed by a presentation on AAEM. The cost of the program is borne completely by AAEM.

AAEM Physician Group (AAEM-PG). This program was announced at the 2016 AAEM Scientific Assembly. AAEM-PG establishes and supports EM practices where physicians can operate democratically and have an equal voice. It is a practice that is run by the local physicians for the physicians. AAEM-PG will help guide new as well as established EM groups, providing for physicians’ autonomy, fair and equitable practice environments, and career and group longevity.

AAEM Resident and Student Association

Victoria Weston, MD, AAEM/RSA President

Overview. Started in 2005, AAEM/RAS now has over 3,500 members and 58 EM residency programs with 100% participation. Benefits of membership include access to EM:RAP and The Journal of Emergency Medicine, access and opportunities to contribute to an RSA peer-reviewed blog and Modern Resident, and free registration for the AAEM Annual Scientific Assembly. As part of the AAEM Scientific Assembly, AAEM/RSA coordinates a day-long education track in collaboration with the AAEM Young Physician Section, an In-Training Exam review, and a Career Fair and Social.

Congressional Elective. Members of AAEM/RSA can apply to be selected for a one-month “Congressional Elective” with Congressmen Raul Ruiz and Joe Heck, the only two EPs currently in Congress, to teach EPs the process of creating health-policy legislation on Capitol Hill. For 4 weeks, residents work directly in their congressional office and learn to work with constituents to develop relevant health-policy legislation. Residents learn to present legislative briefs, proposals, and research in a productive, succinct, and time-efficient manner. AAEM/RSA also offers an annual Advocacy Day, where residents and students have the opportunity to meet with members of Congress and/or senior congressional staff on Capitol Hill; this year it will be held on June 14, 2016 in Washington, DC.

Toxicology Mobile App. The AAEM/RSA Toxicology mobile app will soon be available for purchase, and is compatible with both iPhone and Android technology. You can search by subject, browse chapters of AAEM/RSA’s Toxicology Handbook, or contact Poison Control with a single click.

American Board of Emergency Medicine

Francis L. Counselman, MD, Immediate Past President, ABEM

Enhanced Oral (eOral) Certification Examination. ABEM has completed its second eOral examination; the third is scheduled for April 2016. Three of the examination cases are now in the new eOral format, which uses a computer monitor, patient avatar, picture archiving and communication system (PACS)-quality radiographs, and dynamic rhythm strips. Feedback from test-takers and examiners has been quite positive. ABEM will be moving more cases to the eOral format in the near future.

ABEM Director of Medical Affairs. ABEM has named its first ever Director of Medical Affairs (DMA): Melissa A. Barton, MD. Dr Barton is a former EM Residency Program Director and has been an ABEM Oral Examiner for the past 10 years. She is the recipient of several teaching and leadership awards. Dr Barton will focus on clinically oriented special projects and represent ABEM’s interests to external organizations.

Emergency Medicine Subspecialties. EM now has 13 subspecialty opportunities for EPs; that’s more than double the number from just 5 years ago. Emergency Medical Services (EMS) now has the most ABEM diplomates (445), followed by Medical Toxicology (367) and Pediatric Emergency Medicine (245).

Lifelong Learning and Self-Assessment (LLSA) Test Accessibility. To provide LLSA readings that better match a diplomate’s area of practice, the EMS and Medical Toxicology LLSA readings and tests can now be used by any diplomate to fulfill his or her Maintenance of Certification (MOC) Part II requirements. Pediatric EM LLSA readings and tests will eventually be made available to all diplomates at a later date. All LLSAs can be accessed through the ABEM Web site (https://www.abem.org).

Maintenance of Certification (MOC) Adds Value. In a survey of ABEM diplomates taking the 2014 ConCert Examination, 92.5% found value in maintaining their ABEM certification. In a follow-up survey in 2015, 90.4% stated their medical knowledge was reinforced and/or increased by preparing and taking the ConCert Examination. In addition to being relevant to our diplomates’ practice, ABEM has worked hard to control MOC costs. ABEM has not increased its fees for the last 5 years for the LLSAs; for all remaining examinations, there has been no fee increase for the past 4 years. When compared to all other boards, the expense of the ABEM MOC Program is at the median, costing EPs approximately $265 per year, or about $5 each week.

American College of Emergency Physicians

Jay A. Kaplan, MD, FACEP, ACEP President

Physician Burnout. Unfortunately, EM leads all specialties in the frequency of physician burnout. Emergency physicians must be aware of burnout, and take proactive steps to avoid it. To help EPs, ACEP has organized an “Emergency Medicine Wellness Week.” Prevention tips include eating well, getting the proper amount of sleep, regular exercise, and improving the work environment. In 2016, Wellness Week ran from January 24 to 30; there is a continuing focus on building resilience and preventing compassion fatigue.

Out of Network (OON) Balance Billing. Insurance companies know that it is solely the cost of insurance premiums that consumers pay attention to, not deductibles or exactly what the insurance covers. Those same insurance companies have been adept at portraying physicians as the cause of “surprise billing.” Emergency physicians need to change the conversation from “surprise billing” to “surprise coverage.” We need to talk about fair coverage for our patients, rather than asking for fair payment for physicians (the latter will follow the former and legislators believe that physicians are already fairly paid). ACEP is considering legal action against CMS and the Center for Consumer Information and Insurance Oversight regarding their final rule on “the greatest of three,” which establishes guidelines for how physicians are to be paid for services rendered.

Pay for Performance and Value-based Reimbursement. ACEP has created a joint task force with the Emergency Department Practice Management Association to create a toolbox for EPs to navigate the changing reimbursement landscape. This includes model legislation and best practices, and there is exploration regarding developing alternative payment models for EM.

Opioid Epidemic. ACEP is a participant in the White House working group exploring this epidemic and identifying strategies to combat this national problem. ACEP has sent a letter to CMS and Health and Human Services (HHS) requesting removal of the pain questions from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. Emergency physicians should not be penalized on these surveys for not prescribing narcotic analgesics to patients who could be treated appropriately with nonnarcotic medications. ACEP similarly is considering sending a letter to The Joint Commission requesting removal of their emphasis on pain as the “fifth vital sign.”

Mass Casualty Incidents. ACEP has created a “New High-Threat High-Casualty Task Force” to identify best practice recommendations for provision of emergency care in high-threat environments and identify current clinical and operational knowledge gaps surrounding the issue. This in turn will help prioritize future ACEP research objectives based on these gaps. In addition, a white paper is being prepared, highlighting current national efforts and recommending clinical practice guidelines for adults and pediatric patients, as well as a future strategy for ACEP engagement as a national leader in the area of high-threat emergency care.

Diversity. There is a recognized need to increase the diversity in our current and future EM leadership. To that end, ACEP sponsored a Diversity Summit on April 14, 2016 in Dallas to explore these issues and make recommendations.

Emergency Quality Network. ACEP, along with 38 other health care organizations, received a grant in the CMS Transforming Clinical Practice Initiative to help physicians achieve large-scale health transformation. Areas of EM focus include: improving outcomes for patients with sepsis; reducing avoidable imaging in low-risk patients through implementation of ACEP’s Choosing Wisely campaign; and improving the value of ED chest pain evaluation in low-risk patients by reducing avoidable testing and admissions.

Editor’s Note: Part 2 of this article will appear in the May 2016 issue of Emergency Medicine and will feature reports from the Council of Emergency Medicine Residency Directors (CORD), the Emergency Medicine Residents’ Association (EMRA), and the Society for Academic Emergency Medicine (SAEM). Have a comment or question about this article? Let us know: [email protected].

On February 21 to 24, 2016, the Association of Academic Chairs of Emergency Medicine (AACEM) held its 8th annual retreat in Tempe, Arizona. The AACEM is comprised of full, acting, interim, and emeritus chairs and directors of departments of emergency medicine (EM) who work to improve and support academic departments of EM in the advancement of health care through high-quality education and research.

During that event, AACEM President Greg Volturo, MD, organized a panel discussion of EM leaders to provide an update on their organizations’ recent activities. This panel included representatives from seven prominent EM organizations: the American Academy of Emergency Medicine (AAEM), AAEM Resident and Student Association (AAEM/RSA), American Board of Emergency Medicine (ABEM), American College of Emergency Physicians (ACEP), Council of Emergency Medicine Residency Directors (CORD), Emergency Medicine Residents’ Association (EMRA),  and Society for Academic Emergency Medicine (SAEM).

The following is the first of a two-part article that provides highlights from that discussion, with reports from the AAEM, AAEM/RSA, ABEM, and ACEP. Part 2 will appear in the May issue and will include reports from the CORD, EMRA, and SAEM.

American Academy of Emergency Medicine

Kevin G. Rodgers, MD, FAAEM, President AAEM

Due Process. AAEM highlighted the problem of the lack of due process for many emergency physicians (EPs). By agreeing to waive their rights to due process when signing contracts with some contract management companies, EPs can unwittingly give their employers the power to terminate them without cause and without notice. AAEM is working with Centers for Medicare & Medicaid Services (CMS) and several congressmen to amend the Medicare Rules for Participation to include an “unwaivable due process guarantee.” In addition, AAEM is requesting an addition to the current Code of Federal Regulation to ensure EPs are entitled “to a fair hearing and appellate review through hospital medical staff mechanisms before any termination or restriction of their professional activity or medical staff privileges. These rights cannot be denied through a third party contract.”

AAEM Residency Visitation Program. AAEM is committed to visiting every EM residency program once every 3 to 4 years, similar to the ACEP and ABEM programs. Residency programs will have the opportunity to select from a list of well-known EM speakers; they will deliver a clinically oriented lecture, followed by a presentation on AAEM. The cost of the program is borne completely by AAEM.

AAEM Physician Group (AAEM-PG). This program was announced at the 2016 AAEM Scientific Assembly. AAEM-PG establishes and supports EM practices where physicians can operate democratically and have an equal voice. It is a practice that is run by the local physicians for the physicians. AAEM-PG will help guide new as well as established EM groups, providing for physicians’ autonomy, fair and equitable practice environments, and career and group longevity.

AAEM Resident and Student Association

Victoria Weston, MD, AAEM/RSA President

Overview. Started in 2005, AAEM/RAS now has over 3,500 members and 58 EM residency programs with 100% participation. Benefits of membership include access to EM:RAP and The Journal of Emergency Medicine, access and opportunities to contribute to an RSA peer-reviewed blog and Modern Resident, and free registration for the AAEM Annual Scientific Assembly. As part of the AAEM Scientific Assembly, AAEM/RSA coordinates a day-long education track in collaboration with the AAEM Young Physician Section, an In-Training Exam review, and a Career Fair and Social.

Congressional Elective. Members of AAEM/RSA can apply to be selected for a one-month “Congressional Elective” with Congressmen Raul Ruiz and Joe Heck, the only two EPs currently in Congress, to teach EPs the process of creating health-policy legislation on Capitol Hill. For 4 weeks, residents work directly in their congressional office and learn to work with constituents to develop relevant health-policy legislation. Residents learn to present legislative briefs, proposals, and research in a productive, succinct, and time-efficient manner. AAEM/RSA also offers an annual Advocacy Day, where residents and students have the opportunity to meet with members of Congress and/or senior congressional staff on Capitol Hill; this year it will be held on June 14, 2016 in Washington, DC.

Toxicology Mobile App. The AAEM/RSA Toxicology mobile app will soon be available for purchase, and is compatible with both iPhone and Android technology. You can search by subject, browse chapters of AAEM/RSA’s Toxicology Handbook, or contact Poison Control with a single click.

American Board of Emergency Medicine

Francis L. Counselman, MD, Immediate Past President, ABEM

Enhanced Oral (eOral) Certification Examination. ABEM has completed its second eOral examination; the third is scheduled for April 2016. Three of the examination cases are now in the new eOral format, which uses a computer monitor, patient avatar, picture archiving and communication system (PACS)-quality radiographs, and dynamic rhythm strips. Feedback from test-takers and examiners has been quite positive. ABEM will be moving more cases to the eOral format in the near future.

ABEM Director of Medical Affairs. ABEM has named its first ever Director of Medical Affairs (DMA): Melissa A. Barton, MD. Dr Barton is a former EM Residency Program Director and has been an ABEM Oral Examiner for the past 10 years. She is the recipient of several teaching and leadership awards. Dr Barton will focus on clinically oriented special projects and represent ABEM’s interests to external organizations.

Emergency Medicine Subspecialties. EM now has 13 subspecialty opportunities for EPs; that’s more than double the number from just 5 years ago. Emergency Medical Services (EMS) now has the most ABEM diplomates (445), followed by Medical Toxicology (367) and Pediatric Emergency Medicine (245).

Lifelong Learning and Self-Assessment (LLSA) Test Accessibility. To provide LLSA readings that better match a diplomate’s area of practice, the EMS and Medical Toxicology LLSA readings and tests can now be used by any diplomate to fulfill his or her Maintenance of Certification (MOC) Part II requirements. Pediatric EM LLSA readings and tests will eventually be made available to all diplomates at a later date. All LLSAs can be accessed through the ABEM Web site (https://www.abem.org).

Maintenance of Certification (MOC) Adds Value. In a survey of ABEM diplomates taking the 2014 ConCert Examination, 92.5% found value in maintaining their ABEM certification. In a follow-up survey in 2015, 90.4% stated their medical knowledge was reinforced and/or increased by preparing and taking the ConCert Examination. In addition to being relevant to our diplomates’ practice, ABEM has worked hard to control MOC costs. ABEM has not increased its fees for the last 5 years for the LLSAs; for all remaining examinations, there has been no fee increase for the past 4 years. When compared to all other boards, the expense of the ABEM MOC Program is at the median, costing EPs approximately $265 per year, or about $5 each week.

American College of Emergency Physicians

Jay A. Kaplan, MD, FACEP, ACEP President

Physician Burnout. Unfortunately, EM leads all specialties in the frequency of physician burnout. Emergency physicians must be aware of burnout, and take proactive steps to avoid it. To help EPs, ACEP has organized an “Emergency Medicine Wellness Week.” Prevention tips include eating well, getting the proper amount of sleep, regular exercise, and improving the work environment. In 2016, Wellness Week ran from January 24 to 30; there is a continuing focus on building resilience and preventing compassion fatigue.

Out of Network (OON) Balance Billing. Insurance companies know that it is solely the cost of insurance premiums that consumers pay attention to, not deductibles or exactly what the insurance covers. Those same insurance companies have been adept at portraying physicians as the cause of “surprise billing.” Emergency physicians need to change the conversation from “surprise billing” to “surprise coverage.” We need to talk about fair coverage for our patients, rather than asking for fair payment for physicians (the latter will follow the former and legislators believe that physicians are already fairly paid). ACEP is considering legal action against CMS and the Center for Consumer Information and Insurance Oversight regarding their final rule on “the greatest of three,” which establishes guidelines for how physicians are to be paid for services rendered.

Pay for Performance and Value-based Reimbursement. ACEP has created a joint task force with the Emergency Department Practice Management Association to create a toolbox for EPs to navigate the changing reimbursement landscape. This includes model legislation and best practices, and there is exploration regarding developing alternative payment models for EM.

Opioid Epidemic. ACEP is a participant in the White House working group exploring this epidemic and identifying strategies to combat this national problem. ACEP has sent a letter to CMS and Health and Human Services (HHS) requesting removal of the pain questions from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. Emergency physicians should not be penalized on these surveys for not prescribing narcotic analgesics to patients who could be treated appropriately with nonnarcotic medications. ACEP similarly is considering sending a letter to The Joint Commission requesting removal of their emphasis on pain as the “fifth vital sign.”

Mass Casualty Incidents. ACEP has created a “New High-Threat High-Casualty Task Force” to identify best practice recommendations for provision of emergency care in high-threat environments and identify current clinical and operational knowledge gaps surrounding the issue. This in turn will help prioritize future ACEP research objectives based on these gaps. In addition, a white paper is being prepared, highlighting current national efforts and recommending clinical practice guidelines for adults and pediatric patients, as well as a future strategy for ACEP engagement as a national leader in the area of high-threat emergency care.

Diversity. There is a recognized need to increase the diversity in our current and future EM leadership. To that end, ACEP sponsored a Diversity Summit on April 14, 2016 in Dallas to explore these issues and make recommendations.

Emergency Quality Network. ACEP, along with 38 other health care organizations, received a grant in the CMS Transforming Clinical Practice Initiative to help physicians achieve large-scale health transformation. Areas of EM focus include: improving outcomes for patients with sepsis; reducing avoidable imaging in low-risk patients through implementation of ACEP’s Choosing Wisely campaign; and improving the value of ED chest pain evaluation in low-risk patients by reducing avoidable testing and admissions.

Editor’s Note: Part 2 of this article will appear in the May 2016 issue of Emergency Medicine and will feature reports from the Council of Emergency Medicine Residency Directors (CORD), the Emergency Medicine Residents’ Association (EMRA), and the Society for Academic Emergency Medicine (SAEM). Have a comment or question about this article? Let us know: [email protected].

A February 16, 2016 study in JAMA on in-hospital outcomes and costs among patients hospitalized during a return visit to the ED by Sabbatini et al (2016;315[7]:663-671) provides compelling evidence that the number of unscheduled return visits to an ED within 30 days should not be considered a quality measure of ED care. Though the findings of this important study should provide reassurance that emergency physicians (EPs) and EDs provide quality care, the way the paper’s conclusion was framed makes one wonder whether we EPs tend to judge ourselves too harshly.

Sabbatini et al analyzed Healthcare Cost and Utilization Project data on 9,036,483 patients ages 18 years or older who visited 424 hospital EDs in Florida and New York from February through November 2013, and found that of the 7,278,124 patients who were initially discharged, 1,205,865 returned to the ED within 30 days. Of the returning patients, the 86,012 who were admitted to the hospital within 7 days of the initial visit had significantly lower rates of in-hospital mortality, ICU admissions, and mean costs of hospitalization, but slightly higher inpatient lengths of stay, compared with the 1,609,145 patients who had been admitted on their initial ED visits. Similar outcomes were observed for patients who returned to the ED and were admitted within 14 and 30 days of their initial ED visits. In contrast, patients readmitted upon return to the ED after hospital discharge had higher rates of inpatient mortality and ICU admissions, longer lengths of stay, and higher costs during their repeat hospitalizations compared with the hospitalizations of patients admitted during their initial ED visit with no return ED visits after discharge.

To James Adams, MD, in an editorial accompanying the study (JAMA. 2016;315[7]:659-660), these numbers suggest that neither misdiagnosis nor inadequate treatment on an initial ED visit appear to be the primary causes of return visits to EDs that result in admissions and do not indicate a failure of ED care. However, the authors of the paper—mostly EPs—framed their conclusion somewhat differently, writing “these findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit,” implying, perhaps, that there are ED quality-of-care deficits but that the number of return ED visits followed by admissions does not capture them. An alternatively worded, accurate conclusion about the findings might be “hospitalizations associated with return visits to an ED do not appear to indicate a quality-of-care deficit.”

An unfortunate choice of words or an overly critical view of EP performance? In this issue of Emergency Medicine, there are other examples suggesting that EPs’ perception of their performance—and perhaps by extension, satisfaction with their roles—may be problematic.

In “Allegations: Current Trends in Medical Malpractice, Part 2” (pages 158-162), McCammon and Jennings note that EP’s perception of their malpractice risk ranks higher than that of other physicians’ perception of their risks, despite the findings of a 1991-2005 review of malpractice claims ranking EM in the middle of all specialties with respect to annual risk of claims. “What’s Hot and What’s Not in Our National Organizations: an Emergency Medicine Panel” reports on the most important issues facing emergency medicine (pages 163-166). ACEP President Jay Kaplan, MD, begins by noting that “EM leads all specialties in the frequency of physician burnout.”

Why the pessimism, the unfounded concerns over malpractice risk, the acceptance of possible deficits in the quality of emergency care we provide that may or may not actually exist? After years of listening to unsubstantiated concerns about malpractice suits and quality issues from administrators and regulators, along with dire warnings about EM burnout from other specialists, are we actually beginning to believe them? Doing so would only perpetuate these myths and possibly even discourage the type of high-quality study demonstrated by the efforts of Sabbatini et al. Emergency physicians fulfill an increasingly important central role in health care and have much to be proud of, so let’s insist on evidence-based findings and not accept half-truths or less from anyone. As an essential specialty practiced by highly valued specialists, we deserve better!

A February 16, 2016 study in JAMA on in-hospital outcomes and costs among patients hospitalized during a return visit to the ED by Sabbatini et al (2016;315[7]:663-671) provides compelling evidence that the number of unscheduled return visits to an ED within 30 days should not be considered a quality measure of ED care. Though the findings of this important study should provide reassurance that emergency physicians (EPs) and EDs provide quality care, the way the paper’s conclusion was framed makes one wonder whether we EPs tend to judge ourselves too harshly.

Sabbatini et al analyzed Healthcare Cost and Utilization Project data on 9,036,483 patients ages 18 years or older who visited 424 hospital EDs in Florida and New York from February through November 2013, and found that of the 7,278,124 patients who were initially discharged, 1,205,865 returned to the ED within 30 days. Of the returning patients, the 86,012 who were admitted to the hospital within 7 days of the initial visit had significantly lower rates of in-hospital mortality, ICU admissions, and mean costs of hospitalization, but slightly higher inpatient lengths of stay, compared with the 1,609,145 patients who had been admitted on their initial ED visits. Similar outcomes were observed for patients who returned to the ED and were admitted within 14 and 30 days of their initial ED visits. In contrast, patients readmitted upon return to the ED after hospital discharge had higher rates of inpatient mortality and ICU admissions, longer lengths of stay, and higher costs during their repeat hospitalizations compared with the hospitalizations of patients admitted during their initial ED visit with no return ED visits after discharge.

To James Adams, MD, in an editorial accompanying the study (JAMA. 2016;315[7]:659-660), these numbers suggest that neither misdiagnosis nor inadequate treatment on an initial ED visit appear to be the primary causes of return visits to EDs that result in admissions and do not indicate a failure of ED care. However, the authors of the paper—mostly EPs—framed their conclusion somewhat differently, writing “these findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit,” implying, perhaps, that there are ED quality-of-care deficits but that the number of return ED visits followed by admissions does not capture them. An alternatively worded, accurate conclusion about the findings might be “hospitalizations associated with return visits to an ED do not appear to indicate a quality-of-care deficit.”

An unfortunate choice of words or an overly critical view of EP performance? In this issue of Emergency Medicine, there are other examples suggesting that EPs’ perception of their performance—and perhaps by extension, satisfaction with their roles—may be problematic.

In “Allegations: Current Trends in Medical Malpractice, Part 2” (pages 158-162), McCammon and Jennings note that EP’s perception of their malpractice risk ranks higher than that of other physicians’ perception of their risks, despite the findings of a 1991-2005 review of malpractice claims ranking EM in the middle of all specialties with respect to annual risk of claims. “What’s Hot and What’s Not in Our National Organizations: an Emergency Medicine Panel” reports on the most important issues facing emergency medicine (pages 163-166). ACEP President Jay Kaplan, MD, begins by noting that “EM leads all specialties in the frequency of physician burnout.”

Why the pessimism, the unfounded concerns over malpractice risk, the acceptance of possible deficits in the quality of emergency care we provide that may or may not actually exist? After years of listening to unsubstantiated concerns about malpractice suits and quality issues from administrators and regulators, along with dire warnings about EM burnout from other specialists, are we actually beginning to believe them? Doing so would only perpetuate these myths and possibly even discourage the type of high-quality study demonstrated by the efforts of Sabbatini et al. Emergency physicians fulfill an increasingly important central role in health care and have much to be proud of, so let’s insist on evidence-based findings and not accept half-truths or less from anyone. As an essential specialty practiced by highly valued specialists, we deserve better!

A February 16, 2016 study in JAMA on in-hospital outcomes and costs among patients hospitalized during a return visit to the ED by Sabbatini et al (2016;315[7]:663-671) provides compelling evidence that the number of unscheduled return visits to an ED within 30 days should not be considered a quality measure of ED care. Though the findings of this important study should provide reassurance that emergency physicians (EPs) and EDs provide quality care, the way the paper’s conclusion was framed makes one wonder whether we EPs tend to judge ourselves too harshly.

Sabbatini et al analyzed Healthcare Cost and Utilization Project data on 9,036,483 patients ages 18 years or older who visited 424 hospital EDs in Florida and New York from February through November 2013, and found that of the 7,278,124 patients who were initially discharged, 1,205,865 returned to the ED within 30 days. Of the returning patients, the 86,012 who were admitted to the hospital within 7 days of the initial visit had significantly lower rates of in-hospital mortality, ICU admissions, and mean costs of hospitalization, but slightly higher inpatient lengths of stay, compared with the 1,609,145 patients who had been admitted on their initial ED visits. Similar outcomes were observed for patients who returned to the ED and were admitted within 14 and 30 days of their initial ED visits. In contrast, patients readmitted upon return to the ED after hospital discharge had higher rates of inpatient mortality and ICU admissions, longer lengths of stay, and higher costs during their repeat hospitalizations compared with the hospitalizations of patients admitted during their initial ED visit with no return ED visits after discharge.

To James Adams, MD, in an editorial accompanying the study (JAMA. 2016;315[7]:659-660), these numbers suggest that neither misdiagnosis nor inadequate treatment on an initial ED visit appear to be the primary causes of return visits to EDs that result in admissions and do not indicate a failure of ED care. However, the authors of the paper—mostly EPs—framed their conclusion somewhat differently, writing “these findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit,” implying, perhaps, that there are ED quality-of-care deficits but that the number of return ED visits followed by admissions does not capture them. An alternatively worded, accurate conclusion about the findings might be “hospitalizations associated with return visits to an ED do not appear to indicate a quality-of-care deficit.”

An unfortunate choice of words or an overly critical view of EP performance? In this issue of Emergency Medicine, there are other examples suggesting that EPs’ perception of their performance—and perhaps by extension, satisfaction with their roles—may be problematic.

In “Allegations: Current Trends in Medical Malpractice, Part 2” (pages 158-162), McCammon and Jennings note that EP’s perception of their malpractice risk ranks higher than that of other physicians’ perception of their risks, despite the findings of a 1991-2005 review of malpractice claims ranking EM in the middle of all specialties with respect to annual risk of claims. “What’s Hot and What’s Not in Our National Organizations: an Emergency Medicine Panel” reports on the most important issues facing emergency medicine (pages 163-166). ACEP President Jay Kaplan, MD, begins by noting that “EM leads all specialties in the frequency of physician burnout.”

Why the pessimism, the unfounded concerns over malpractice risk, the acceptance of possible deficits in the quality of emergency care we provide that may or may not actually exist? After years of listening to unsubstantiated concerns about malpractice suits and quality issues from administrators and regulators, along with dire warnings about EM burnout from other specialists, are we actually beginning to believe them? Doing so would only perpetuate these myths and possibly even discourage the type of high-quality study demonstrated by the efforts of Sabbatini et al. Emergency physicians fulfill an increasingly important central role in health care and have much to be proud of, so let’s insist on evidence-based findings and not accept half-truths or less from anyone. As an essential specialty practiced by highly valued specialists, we deserve better!

Will you get paid for conducting a prebaby visit in your practice? Probably not in income, but certainly in long-term benefits to your care of the incoming child and family.

While parents are coached by websites to determine such things as your fees, what insurance you take, your credentials, age, gender, practice structure, hours, and availability, all these questions can be handled by your front desk or nursing staff or a handout. The really valuable conversations are the ones that you have that help the imminent parents begin to understand the sometimes subtle factors influencing the parenting they will undertake.

Pregnancy brings mental and emotional changes in a predicable pattern that is useful to understand. In the first trimester, the prospective parents become aware of their gender and sexuality in a new way, usually with pride and confirmation. For teenagers, this may not be welcomed by the family and may even place them at risk for being put out of the house. The fetus, however, is not very real to the parents at this point, except through the morning sickness that mothers – and even some empathetic fathers – experience. You are not likely to see the family in the first trimester unless an early ultrasound or genetic test raises concerns that require decisions.

In the second trimester, the gender is often revealed, making the child seem much more real. Men may spend a lot of time thinking about finances and how to support the upcoming demands. Some men deal with the impending departure of their freedom by taking up a new hobby, making the mother nervous about their commitment to helping with the baby in the future. In these months, prospective parents often have dreams of a deformed infant or other scary imaginings about forgetting or harming the baby. Older parents or those with a history of miscarriage or infertility may be particularly worried about possible abnormalities, but these fears are quite common among all parents. You can reassure parents that these dreams may be a way of helping them “be ready for anything.” The responsibility of parenting already has begun in needing to avoid medications, alcohol, and smoking – at least for the mother. While the father also may be abstaining in support, he may be oblivious, and the mother may be suffering alone and concerned about his future support in parenting.

The third trimester is the time parents come up with names, prep the bedroom, pack the suitcase, and make concrete plans for the delivery but also face the reality that delivering a baby has huge potential dangers as well as joys.

The third trimester is the most common time for a visit to interview pediatricians, and these issues are not far from the surface – if you ask. The goal of a prebaby visit – of forming a supportive relationship with the parents without a baby yet present – is multifactorial. It is best approached by:

• Asking about the history of previous pregnancies and the course of the current pregnancy so far.

• Asking whether flu and Tdap vaccines were given.

• Asking whether there have there been any complications or exposures to infections, medications, smoke, alcohol, or drugs.

• Congratulating abstinence and acknowledging all the ways that the parents have been “taking good care of this baby already.”

More parents are questioning the use of vaccines and antibiotics these days, and they may want to discuss your views or policies on these. Having handouts available on these plus ones on car seats, smoke exposure, supine sleeping position, safe crib accessories, and the expected newborn tests is important for all parents because these standards keep changing. While most practices want to attract new patients, be honest because sometimes parents are not a good fit!

Delivery method is not completely a choice, but put in a word about avoiding general anesthesia for the sake of the baby, which is not likely to have been on the parents’ minds. This is the chance to get them excited about the unique alertness their newborn will have in the first hour after birth under the influence of labor stress, giving them the chance to lock gaze in a moment they will never forget!

Asking “How do you plan to feed the baby?” rather than just “breast or bottle” gives you a chance to inform them of your team’s expertise and your support for their choice, but may also reveal ambivalences worth exploring. The prospect of breastfeeding often brings out fears of failure from the mother, but surprisingly, some fathers are possessive about their partner’s breasts and not willing to share. Some mothers are so modest that breastfeeding is taboo. A motivational interviewing style “pros and cons” discussion of nursing is in order, but may not budge those beliefs. In this age of safe formula, you need not strain your relationship to convince them. Such extremes in the family are quite likely to reemerge as issues later in the need to “surrender” to the requirements of childrearing, however.

You may think that taking a family history to understand health risks will soon be obviated by genomic testing or a shared electronic medical record. I believe that it will always have special value at the prebaby visit, whether that information is available or not. In eliciting a history of any potentially hereditary conditions, the key is to assure families that you will be on their team to provide the best medical care for any eventuality. But this is also the time to ask about each family member, their education, employment, and medical conditions, including mental health and substance use. In the process, you are likely to hear about any estrangements, abuse, divorces, dependent relatives, and just plain family stress that will impact on this newly forming family. The question, “Who will you have to help you with the baby?” will elicit social support, but also concerns about fears of intrusive relatives or demands of dependent family members. Parents will thank you later for suggesting a doula, inviting relatives to takes turns coming to help after the first 2 “settling in” weeks when the father has to go back to work, or arranging a sitter for older siblings even though mother is home! This is a good moment to discuss prebaby classes and strategies for supporting any siblings at this big transition with daily special time. It is a valuable service to have resource listings for child care as this may be a bigger stress than concerns about delivery!

Even if they already know the baby’s sex, I like to ask, “Were you hoping for a girl or a boy?” (and why) as a way to elicit gender bias, in addition to finding out about risk for genetic conditions. Such bias may later become relevant, especially for toddler discipline, which presents as the “prejudiced parent syndrome” of overly lax or overly strong punishment. Turning to the father and asking, “What are your ideas about circumcision?” is sure to engage his attention and show that you expect him to be an active participant in decisions in what may have seemed a female process so far. If they have not decided or are actively disagreeing, you may express curiosity about “how they usually decide things together.” Be sure to recommend local anesthesia for circumcision, if planned!

Parental bias about gender also may come from negative experiences when the parent was growing up, such as a whiny sister or hyperactive cousin. Verbalizing that “everyone has memories from how we were raised that we may or may not want to repeat” is a great opener for asking, “What was it like when you were growing up? What would you like to do the same way and what differently?” This is an appropriate time to ask about their marriage and whether this was “a good time to have a baby.” Although most pregnancies are unplanned, it is the norm for parents to have come to an acceptance and excitement about the pregnancy by the second trimester. If you detect marital discord or depression, making a referral now is very important, rather than waiting in hopes it will resolve when the baby comes. With all its joys, studies show that the arrival of a baby is a huge stress that tends to worsen the parental relationship. Plus, they have more time to get to help now than they will after delivery!

Having a baby is life’s biggest commitment, adventure, and joy. Showing parents in the prebaby visit that you care about them, their values, and questions, and not just the medical care of their child can quickly establish a deep understanding that will inform all future contacts – making communication easier, more effective, and more meaningful.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication is as a paid expert to Frontline Medical Communications. E-mail her at [email protected].

Will you get paid for conducting a prebaby visit in your practice? Probably not in income, but certainly in long-term benefits to your care of the incoming child and family.

While parents are coached by websites to determine such things as your fees, what insurance you take, your credentials, age, gender, practice structure, hours, and availability, all these questions can be handled by your front desk or nursing staff or a handout. The really valuable conversations are the ones that you have that help the imminent parents begin to understand the sometimes subtle factors influencing the parenting they will undertake.

Pregnancy brings mental and emotional changes in a predicable pattern that is useful to understand. In the first trimester, the prospective parents become aware of their gender and sexuality in a new way, usually with pride and confirmation. For teenagers, this may not be welcomed by the family and may even place them at risk for being put out of the house. The fetus, however, is not very real to the parents at this point, except through the morning sickness that mothers – and even some empathetic fathers – experience. You are not likely to see the family in the first trimester unless an early ultrasound or genetic test raises concerns that require decisions.

In the second trimester, the gender is often revealed, making the child seem much more real. Men may spend a lot of time thinking about finances and how to support the upcoming demands. Some men deal with the impending departure of their freedom by taking up a new hobby, making the mother nervous about their commitment to helping with the baby in the future. In these months, prospective parents often have dreams of a deformed infant or other scary imaginings about forgetting or harming the baby. Older parents or those with a history of miscarriage or infertility may be particularly worried about possible abnormalities, but these fears are quite common among all parents. You can reassure parents that these dreams may be a way of helping them “be ready for anything.” The responsibility of parenting already has begun in needing to avoid medications, alcohol, and smoking – at least for the mother. While the father also may be abstaining in support, he may be oblivious, and the mother may be suffering alone and concerned about his future support in parenting.

The third trimester is the time parents come up with names, prep the bedroom, pack the suitcase, and make concrete plans for the delivery but also face the reality that delivering a baby has huge potential dangers as well as joys.

The third trimester is the most common time for a visit to interview pediatricians, and these issues are not far from the surface – if you ask. The goal of a prebaby visit – of forming a supportive relationship with the parents without a baby yet present – is multifactorial. It is best approached by:

• Asking about the history of previous pregnancies and the course of the current pregnancy so far.

• Asking whether flu and Tdap vaccines were given.

• Asking whether there have there been any complications or exposures to infections, medications, smoke, alcohol, or drugs.

• Congratulating abstinence and acknowledging all the ways that the parents have been “taking good care of this baby already.”

More parents are questioning the use of vaccines and antibiotics these days, and they may want to discuss your views or policies on these. Having handouts available on these plus ones on car seats, smoke exposure, supine sleeping position, safe crib accessories, and the expected newborn tests is important for all parents because these standards keep changing. While most practices want to attract new patients, be honest because sometimes parents are not a good fit!

Delivery method is not completely a choice, but put in a word about avoiding general anesthesia for the sake of the baby, which is not likely to have been on the parents’ minds. This is the chance to get them excited about the unique alertness their newborn will have in the first hour after birth under the influence of labor stress, giving them the chance to lock gaze in a moment they will never forget!

Asking “How do you plan to feed the baby?” rather than just “breast or bottle” gives you a chance to inform them of your team’s expertise and your support for their choice, but may also reveal ambivalences worth exploring. The prospect of breastfeeding often brings out fears of failure from the mother, but surprisingly, some fathers are possessive about their partner’s breasts and not willing to share. Some mothers are so modest that breastfeeding is taboo. A motivational interviewing style “pros and cons” discussion of nursing is in order, but may not budge those beliefs. In this age of safe formula, you need not strain your relationship to convince them. Such extremes in the family are quite likely to reemerge as issues later in the need to “surrender” to the requirements of childrearing, however.

You may think that taking a family history to understand health risks will soon be obviated by genomic testing or a shared electronic medical record. I believe that it will always have special value at the prebaby visit, whether that information is available or not. In eliciting a history of any potentially hereditary conditions, the key is to assure families that you will be on their team to provide the best medical care for any eventuality. But this is also the time to ask about each family member, their education, employment, and medical conditions, including mental health and substance use. In the process, you are likely to hear about any estrangements, abuse, divorces, dependent relatives, and just plain family stress that will impact on this newly forming family. The question, “Who will you have to help you with the baby?” will elicit social support, but also concerns about fears of intrusive relatives or demands of dependent family members. Parents will thank you later for suggesting a doula, inviting relatives to takes turns coming to help after the first 2 “settling in” weeks when the father has to go back to work, or arranging a sitter for older siblings even though mother is home! This is a good moment to discuss prebaby classes and strategies for supporting any siblings at this big transition with daily special time. It is a valuable service to have resource listings for child care as this may be a bigger stress than concerns about delivery!

Even if they already know the baby’s sex, I like to ask, “Were you hoping for a girl or a boy?” (and why) as a way to elicit gender bias, in addition to finding out about risk for genetic conditions. Such bias may later become relevant, especially for toddler discipline, which presents as the “prejudiced parent syndrome” of overly lax or overly strong punishment. Turning to the father and asking, “What are your ideas about circumcision?” is sure to engage his attention and show that you expect him to be an active participant in decisions in what may have seemed a female process so far. If they have not decided or are actively disagreeing, you may express curiosity about “how they usually decide things together.” Be sure to recommend local anesthesia for circumcision, if planned!

Parental bias about gender also may come from negative experiences when the parent was growing up, such as a whiny sister or hyperactive cousin. Verbalizing that “everyone has memories from how we were raised that we may or may not want to repeat” is a great opener for asking, “What was it like when you were growing up? What would you like to do the same way and what differently?” This is an appropriate time to ask about their marriage and whether this was “a good time to have a baby.” Although most pregnancies are unplanned, it is the norm for parents to have come to an acceptance and excitement about the pregnancy by the second trimester. If you detect marital discord or depression, making a referral now is very important, rather than waiting in hopes it will resolve when the baby comes. With all its joys, studies show that the arrival of a baby is a huge stress that tends to worsen the parental relationship. Plus, they have more time to get to help now than they will after delivery!

Having a baby is life’s biggest commitment, adventure, and joy. Showing parents in the prebaby visit that you care about them, their values, and questions, and not just the medical care of their child can quickly establish a deep understanding that will inform all future contacts – making communication easier, more effective, and more meaningful.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication is as a paid expert to Frontline Medical Communications. E-mail her at [email protected].

Will you get paid for conducting a prebaby visit in your practice? Probably not in income, but certainly in long-term benefits to your care of the incoming child and family.

While parents are coached by websites to determine such things as your fees, what insurance you take, your credentials, age, gender, practice structure, hours, and availability, all these questions can be handled by your front desk or nursing staff or a handout. The really valuable conversations are the ones that you have that help the imminent parents begin to understand the sometimes subtle factors influencing the parenting they will undertake.

Pregnancy brings mental and emotional changes in a predicable pattern that is useful to understand. In the first trimester, the prospective parents become aware of their gender and sexuality in a new way, usually with pride and confirmation. For teenagers, this may not be welcomed by the family and may even place them at risk for being put out of the house. The fetus, however, is not very real to the parents at this point, except through the morning sickness that mothers – and even some empathetic fathers – experience. You are not likely to see the family in the first trimester unless an early ultrasound or genetic test raises concerns that require decisions.

In the second trimester, the gender is often revealed, making the child seem much more real. Men may spend a lot of time thinking about finances and how to support the upcoming demands. Some men deal with the impending departure of their freedom by taking up a new hobby, making the mother nervous about their commitment to helping with the baby in the future. In these months, prospective parents often have dreams of a deformed infant or other scary imaginings about forgetting or harming the baby. Older parents or those with a history of miscarriage or infertility may be particularly worried about possible abnormalities, but these fears are quite common among all parents. You can reassure parents that these dreams may be a way of helping them “be ready for anything.” The responsibility of parenting already has begun in needing to avoid medications, alcohol, and smoking – at least for the mother. While the father also may be abstaining in support, he may be oblivious, and the mother may be suffering alone and concerned about his future support in parenting.

The third trimester is the time parents come up with names, prep the bedroom, pack the suitcase, and make concrete plans for the delivery but also face the reality that delivering a baby has huge potential dangers as well as joys.

The third trimester is the most common time for a visit to interview pediatricians, and these issues are not far from the surface – if you ask. The goal of a prebaby visit – of forming a supportive relationship with the parents without a baby yet present – is multifactorial. It is best approached by:

• Asking about the history of previous pregnancies and the course of the current pregnancy so far.

• Asking whether flu and Tdap vaccines were given.

• Asking whether there have there been any complications or exposures to infections, medications, smoke, alcohol, or drugs.

• Congratulating abstinence and acknowledging all the ways that the parents have been “taking good care of this baby already.”

More parents are questioning the use of vaccines and antibiotics these days, and they may want to discuss your views or policies on these. Having handouts available on these plus ones on car seats, smoke exposure, supine sleeping position, safe crib accessories, and the expected newborn tests is important for all parents because these standards keep changing. While most practices want to attract new patients, be honest because sometimes parents are not a good fit!

Delivery method is not completely a choice, but put in a word about avoiding general anesthesia for the sake of the baby, which is not likely to have been on the parents’ minds. This is the chance to get them excited about the unique alertness their newborn will have in the first hour after birth under the influence of labor stress, giving them the chance to lock gaze in a moment they will never forget!

Asking “How do you plan to feed the baby?” rather than just “breast or bottle” gives you a chance to inform them of your team’s expertise and your support for their choice, but may also reveal ambivalences worth exploring. The prospect of breastfeeding often brings out fears of failure from the mother, but surprisingly, some fathers are possessive about their partner’s breasts and not willing to share. Some mothers are so modest that breastfeeding is taboo. A motivational interviewing style “pros and cons” discussion of nursing is in order, but may not budge those beliefs. In this age of safe formula, you need not strain your relationship to convince them. Such extremes in the family are quite likely to reemerge as issues later in the need to “surrender” to the requirements of childrearing, however.

You may think that taking a family history to understand health risks will soon be obviated by genomic testing or a shared electronic medical record. I believe that it will always have special value at the prebaby visit, whether that information is available or not. In eliciting a history of any potentially hereditary conditions, the key is to assure families that you will be on their team to provide the best medical care for any eventuality. But this is also the time to ask about each family member, their education, employment, and medical conditions, including mental health and substance use. In the process, you are likely to hear about any estrangements, abuse, divorces, dependent relatives, and just plain family stress that will impact on this newly forming family. The question, “Who will you have to help you with the baby?” will elicit social support, but also concerns about fears of intrusive relatives or demands of dependent family members. Parents will thank you later for suggesting a doula, inviting relatives to takes turns coming to help after the first 2 “settling in” weeks when the father has to go back to work, or arranging a sitter for older siblings even though mother is home! This is a good moment to discuss prebaby classes and strategies for supporting any siblings at this big transition with daily special time. It is a valuable service to have resource listings for child care as this may be a bigger stress than concerns about delivery!

Even if they already know the baby’s sex, I like to ask, “Were you hoping for a girl or a boy?” (and why) as a way to elicit gender bias, in addition to finding out about risk for genetic conditions. Such bias may later become relevant, especially for toddler discipline, which presents as the “prejudiced parent syndrome” of overly lax or overly strong punishment. Turning to the father and asking, “What are your ideas about circumcision?” is sure to engage his attention and show that you expect him to be an active participant in decisions in what may have seemed a female process so far. If they have not decided or are actively disagreeing, you may express curiosity about “how they usually decide things together.” Be sure to recommend local anesthesia for circumcision, if planned!

Parental bias about gender also may come from negative experiences when the parent was growing up, such as a whiny sister or hyperactive cousin. Verbalizing that “everyone has memories from how we were raised that we may or may not want to repeat” is a great opener for asking, “What was it like when you were growing up? What would you like to do the same way and what differently?” This is an appropriate time to ask about their marriage and whether this was “a good time to have a baby.” Although most pregnancies are unplanned, it is the norm for parents to have come to an acceptance and excitement about the pregnancy by the second trimester. If you detect marital discord or depression, making a referral now is very important, rather than waiting in hopes it will resolve when the baby comes. With all its joys, studies show that the arrival of a baby is a huge stress that tends to worsen the parental relationship. Plus, they have more time to get to help now than they will after delivery!

Having a baby is life’s biggest commitment, adventure, and joy. Showing parents in the prebaby visit that you care about them, their values, and questions, and not just the medical care of their child can quickly establish a deep understanding that will inform all future contacts – making communication easier, more effective, and more meaningful.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication is as a paid expert to Frontline Medical Communications. E-mail her at [email protected].