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

The following members are candidates for the Board of Directors. They responded to this prompt: What do you believe is the single most divisive issue in ACEP at this time, and how would you address it?

Michael Baker, MD, FACEP (Michigan)

Current Professional Positions: director of telehealth, EPMG/Envision; medical director, Munson Healthcare Cadillac Hospital, Cadillac, Michigan; clinical assistant professor, Michigan State University College of Osteopathic Medicine, East Lansing; adjunct clinical instructor, University of Michigan College of Medicine, Ann Arbor; attending physician, St. Joseph Mercy Hospital, Ann Arbor; core faculty, University of Michigan/St. Joseph Mercy Hospital emergency medicine residency

Internships and Residency: emergency medicine residency, University of Michigan

Medical Degree: MD, Ohio State University, Columbus (1993)

Response

What is the value of emergency board certification when physicians without emergency medicine certification and advanced practice providers (APPs) care for emergency patients? In the 1990s, the closure of the practice track to EM board certification created a schism within emergency medicine between boarded and nonboarded emergency physicians. Meanwhile, ACEP promoted the value of EM board certification. Today, the notable use of APPs and nonemergency boarded physicians has reopened the divisive debate on whether emergency board certification is required to independently care for emergency center patients.

A provider who is not boarded in emergency medicine has neither standardized education nor a certification process in the care of emergency patients, yet we are seeing these providers take an independent role in caring for emergency patients. Emergency patients in the United States are seen by a mix of both emergency physicians and nonemergency providers. An Annals of Emergency Medicine 2018 study revealed that emergency physicians provide two-thirds of the care delivered in the emergency center. Meanwhile, the remaining 33 percent of care was delivered by nonemergency physicians (family medicine and internal medicine) and by APPs.

It doesn’t need to be this way. No other medical provider has the mastery of boarded emergency physicians in the evaluation, diagnosis, and management of acute care issues. ACEP has remained steadfast in its statement that the independent practice of emergency medicine is best performed by a boarded (or board-eligible) emergency physician. Formal residency training and board certification have both been researched and improved over the decades. As a result, emergency medicine residencies and board certification remain integral to ensuring the quality of emergency care delivery. Nevertheless, physician shortages and market pressures have encouraged the use of other care providers in many emergency centers.

To prevent this divisive issue from growing into a schism, ACEP will need insightful leadership to navigate three significant areas. We must narrow the need for providers who are not boarded EM physicians, develop a collaborative environment with such providers, and explore the efficiencies of telemedicine. We can ensure a large, diverse emergency physician workforce by advocating for funding of additional residency training opportunities (especially in underserved areas), supporting board certification improvements, and fighting the causes of burnout that lead to early retirements such as burdensome documentation and the public undervaluing of emergency services by payers.

Second, ACEP needs to review its existing practice policy statements and work with key organizations to ensure policies and practice models that support an evidence-based collaborative care environment with APPs, including training and certification recommendations.

Lastly, ACEP needs to explore the potential for new technologies such as telemedicine and digital health to help emergency physicians efficiently collaborate in the care of an increasingly complex emergency patient population by maximizing the ability to digitally connect emergency patients, APPs, and non-EM physicians with EM boarded physicians.

With insightful ACEP leadership on this divisive issue, we will achieve the ideal of anything, anytime, anyone emergency care provided by a board-certified emergency physician for all emergency patients.

Jeffrey Goodloe, MD, FACEP (Oklahoma)

Current Professional Positions: attending emergency physician, Hillcrest Medical Center Emergency Center, Tulsa, Oklahoma; professor of emergency medicine, EMS section chief, and director, Oklahoma Center for Prehospital & Disaster Medicine, University of Oklahoma School of Community Medicine, Tulsa; chief medical officer, medical control board, EMS System for Metropolitan Oklahoma City & Tulsa; medical director, Oklahoma Highway Patrol; medical director, Tulsa Community College EMS Education Programs

Internships and Residency: emergency medicine residency, Methodist Hospital of Indiana/Indiana University School of Medicine, Indianapolis; EMS fellowship, University of Texas Southwestern Medical Center, Dallas

Medical Degree: MD, Medical School at University of Texas Health Science Center at San Antonio (1995)

Response

I am concerned about the potential threat to civility and decorum within our College given we are increasingly exposed to ad hominem thoughts, commentary, and actions occurring in our larger society. Divisiveness itself may become the single most divisive dynamic within ACEP. We may not achieve, or even need, a formal policy on every issue that catches our attention. The manner with which we responsibly navigate our deliberations, respecting one another, being inclusive in more than words, sincerely valuing one another—the future of our College depends upon us doing so.

Firearms injuries. Gun violence. Responsible gun ownership. These phrases bring immediate emotions palpably disparate within society, which are reflected within our College. Disparity can, and often does, foster divisiveness. A trusted colleague advised, “You’ll be okay in your Board candidacy as long as you stay away from firearms.” Just two weeks later, I was asked a pointed question regarding gun violence. My approach to addressing this and other divisive issues as a candidate for your Board of Directors is clear. I cannot and will not avoid issues that so critically affect our patients and practices, particularly those that engender strong opinions from our members.

As one ACEP member, I certainly am not going to resolve such a complex issue with a few words. Surely, as emergency physicians, we can work to a point of consensus, with due concern about gun-related violence while advocating for evidence-based injury prevention based upon scientifically valid research. As an elected ACEP Board member, I will actively engage in consensus building on this and other polarizing issues affecting our patients, all of us, and society as a whole.

First, for ACEP to pursue formal policy on any issue, the issue must impact the health of our patients or be of legitimate interest to the practice of emergency medicine and emergency physicians. Regardless of facility size or one’s practice setting, most emergency physicians manage preventable gunshot wounds. Clearly, violence involving firearms is an issue for us and our patients.

Second, ACEP must utilize nonbiased data when constructing formal ACEP policy. Even casual consumers of media in any of its forms can be inundated with a dizzying volume of statistics regarding firearms—strongly pro, strongly con, and everywhere in between. ACEP leaders must use credible resources to parse related data carefully, exclude biased research, discard vitriolic rhetoric, confirm valid research, and advocate for research in unvetted areas of importance.

Third, ACEP must act transparently when developing formal policy. Lack of transparency begets lack of confidence begets loss of trust.

Using these tenets in drafting policy, the Board of Directors can then act responsibly in representing members.

Whether firearms injury prevention, gender-related pay and opportunities, contract management group impacts, board certification requirements, or any of the other myriad issues where opinions can vary widely, we must always remember we are all emergency physicians. We must genuinely respect one another, listening with an open mind, valuing the commitments each of us makes to our specialty and to humanity.

Rachelle (Shelley) Greenman, MD, FACEP (NJ)

Current Professional Positions: assistant professor of emergency medicine, Cooper Medical School of Rowan University, Camden, New Jersey

Internships and Residency: internal medicine internship, Montefiore Hospital, Bronx, New York; internal medicine residency, Montefiore Hospital; emergency medicine residency, Jacobi Hospital/Bronx Municipal Hospital Center, Albert Einstein College of Medicine, Bronx

Medical Degree: MD, New Jersey Medical School University of Medicine and Dentistry, Newark (1985)

Response

While there are many issues confronting us that are controversial and divisive, there are few that rival the topic of gun control in its ability to create contention and instigate dispute, as evidenced by two articles published in the May 2019 issue of ACEP Now.

The front-page article by Dr. Megan Ranney emphasized that, as professionals, firearm injury affects us all, outlining actions already undertaken by ACEP, including education and advocacy efforts to improve public safety. Several pages later, Dr. Marco Coppola’s response suggested that the firearm issue is “less about patient safety than about furthering a political agenda.” He writes that ACEP “runs the risk of alienating a good number of members” and “should stay out of divisive issues.”

A 2018 NBC/Wall Street Journal poll found that 80 percent of registered voters believed the country was divided. So, it would come as no surprise that ACEP members are also divided on many issues. As emergency medicine physicians, our obligation is to safeguard and protect our patients and our communities. Patient welfare must always be our top priority even though this may require putting aside partisan leanings and influences.

In a 2018 WSJ op-ed, James A. Baker III wrote, “We have become an evenly divided red-state, blue-state nation more intent on waging political battles than finding ways to advance the common good.”

One need simply recall the straw polls taken at Council preceding the last few presidential elections and note that we, in ACEP, were split virtually down the middle. Despite this, we seem to be able to put aside our differences and focus on doing the right thing for public health and safety.

If we approach any rift with an “us vs. them” attitude, it is unlikely progress will be made. Reframing the gun control discussion as one aimed at reducing injury and death by addressing firearm safety and gun violence without infringing upon the right to own and use firearms will encourage bipartisan conversation and meaningful compromise.

Fortunately, there is history of reaching common ground that can be used as a template for further progress. A 2018 ACEP member survey found that almost 70 percent of respondents supported the current ACEP policy on firearm safety and prevention, with an additional 21 percent supporting some of the policy.

There will always be issues that we disagree on, but with identification of common ground, calm discussion, mutual respect, education, and sincere effort to understand each other’s perspectives, we can work together to effect constructive change. Much can be gained by creating a safe, nonjudgmental environment to express opinions, focusing on big-picture, long-term goals by making small, mutually agreeable compromises. Rather than a “winner take all” mentality, there must be recognition that we are all on the same team working toward a mutual goal. ACEP must work with all concerned to develop a consensus approach incorporating the many different viewpoints in an effort to move forward toward meaningful progress.

Gabor Kelen, MD, FACEP (AACEM)

Current Professional Positions: chair, department of emergency medicine, Johns Hopkins University, Baltimore; physician-in-chief, emergency medicine, Johns Hopkins Medicine; director, Johns Hopkins Office of Critical Event Preparedness and Response; chair, Board of Directors, Johns Hopkins Emergency Medicine Service, LLC; principal staff, Applied Physics Laboratory, Johns Hopkins University; professor of emergency medicine, anesthesiology, and critical care medicine, Johns Hopkins University School of Medicine; professor of health policy and management, Johns Hopkins University School of Public Health

Internships and Residency: internship, University of Toronto, St. Michael’s Hospital; residency, University of Toronto, St. Michael’s Hospital; emergency medicine residency, Johns Hopkins Hospital

Medical Degree: MD, University of Toronto (1979)

Response

I don’t much like focusing on issues that divide us and would rather spend the energy on promoting factors that unite us and keep us as a cohesive body to further the field of emergency medicine for the betterment of patients, physicians, and our allied staff.

That said, there is an issue, perhaps so permeating, that most do not recognize that it is an issue at all—or that it is divisive. Emergency medicine no longer has a unifying defining purpose. There is a multiplicity of purposes, each organization coveting and protective of its uniqueness or niche. There are over 225 EM residencies, and over 75 percent of universities have established autonomous academic departments. Today, EM personalities can dominate an institution. EM has been a primary specialty now for more than 30 years. EM physicians are health system CEOs, state and national surgeon generals, deans of medical schools, entrepreneurs, etc. More and more distinct niche societies allied or stemming from EM wish a strong degree of autonomy and identity.

In its most formative days, pressing the advancement of and seeking recognition as a respected specialty was the clarion call that united virtually all of EM in a singular purpose. In many ways, this was akin to pursuing legitimacy and acceptance, the basis for most social and civil rights movements. This purpose drove the founders and legacy physicians and influenced at least two generations to advance the field. Today, the ascendancy of EM and its rightful place in medicine are not questioned any more than the usual (and unfortunate) disparagement of some specialty members toward another specialty—and sometimes we ourselves give as much as we take.

So, what does this have to do with divisiveness? Since we are not all rowing in the same direction, and don’t particularly have unifying purpose for the specialty, many of our members are adrift. Those of us on Council and leaders of ACEP are generally driven by a strong purpose to improve the lives of our patients and members. But a perusal of EM blogs and other social media discourse reveals that many in EM (including many ACEP members) are adrift. Many feel like they are simply a cog in some organization, without voice and without meaning in their work, simply “processing” patients while having to perform to various metrics—many of which have nothing to do with clinical acumen or patient engagement.

Reinvigorating commonality of purpose such that daily lives of emergency physicians have meaning is not a simple task. However, given the enormity of the situation, even if very underrecognized, solutions are worth exploring. We could start by soliciting suggestions from our members and reaching out to other EM-linked societies. One option would be to convene a summit of sorts with leaders and constituents from the various EM entities (big and small) to allow us to take stock, reaffirm commonality, and develop a new shared vision that a strong majority of emergency physicians can back with energized conviction.

Pamela Ross, MD, FACEP (VA)

Current Professional Positions: CEO and sole proprietor, Holistic Medical Consultants, LLC, Troy, Virginia

Internships and Residency: emergency medicine residency, St. Vincent Medical Center, Toledo, Ohio; pediatric emergency medicine fellowship, Inova Fairfax Medical Campus, Falls Church, Virginia; integrative medicine fellowship, University of Arizona Center for Integrative Medicine, Tucson

Medical Degree: MD, Emory University School of Medicine (1991)

Response

ACEP operates democratically by majority vote of ACEP members present and participating in the ACEP Council. The Council is the collective representation of our membership and includes all states, sections, and other similarly aligned EM organizations like EMRA. The Council democratically elects, advises, and instructs the Board of Directors regarding any matter of importance to any ACEP member. The Council accomplishes this through bylaws, resolutions, and any other action the Council deems necessary. Once elected, management and control of the organization is officially vested in the Board of Directors. If there be any confusion or concern for how we have arrived to where we are on any issue in ACEP today, remember that power in ACEP (as it historically and currently stands) is held solidly in the proceedings of the ACEP Council.

Based on the proceedings of the last official meeting of the Council held October 2018 in San Diego, bearing witness to the political nature of debate and the deeply divided Council deliberations, the single most divisive issue in ACEP at this time is our ACEP Policy on Firearm Safety and Injury Prevention, where Council directed this already-existing policy be updated. There were 51 resolutions presented. While there were about seven other resolutions that rose to similar levels of contention, my selection is validated by opposing articles written by Dr. Megan Ranney and Dr. Marco Coppola, published in the May 2019 issue of ACEP Now.

We won’t get around divisive topics within our organization by carrying on as if they do not exist. We are equally challenged if we try to ignore one side of an issue. We are currently living in deeply divided times and, in the wisdom of Gandhi, world-renowned activist, “Unity, to be real, must stand the severest strain without breaking.” It is important to exercise due diligence to identify all the ways we can stand united. My methods as a leader to address issues of deep organizational division in search of organizational unity include but are not limited to:

Start with me as a leader—poised, open-hearted, collaborative, diplomatic, respectful, strong, and committed to the vision and values of ACEP.

Conduct well-researched, unbiased, scientifically validated surveys of Council and/or membership.

Promote EngagED member feedback and discussion in our 38,700 ACEP members-only online community, https://engaged.acep.org/home.

Facilitate town halls or other meeting forums where members can engage through activities like opposing panel presentations, group discussions, round tables, etc.

Feature opposing articles, research, letters to the editor, etc. in ACEP publications.

Support and facilitate communication between ACEP Board, committees, task forces, chapters, sections, etc. to assure alignment of referred resolutions with ACEP mission/vision.

Systematically review and facilitate exploration/development of resolutions that change organizational operations in ways that most effectively meet member needs and bring the largest possible collective member voice to ACEP.

Continually support and encourage member patience and participation in the process.

Courageously lead in the direction that Council/membership would have our organization go.

Gillian Schmitz, MD, FACEP (incumbent, Government Services)

Current Professional Positions: associate professor, department of military and emergency medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, Maryland; adjunct associate professor, department of emergency medicine, University of Texas Health Science Center at San Antonio

Internships and Residency: emergency medicine, University of North Carolina

Medical Degree: MD, Loyola University Stritch School of Medicine, Chicago (2004)

Response

The single most divisive issue in ACEP is our response, as an organization, to address firearm safety. Many members feel this is an important public health issue that ACEP should take the lead on. Others feel this is a political topic that is outside the scope of the College and any action has the potential to alienate members on both sides. Historically, ACEP members have been split on this issue, which has been reflected in the passion and emotionally charged discussions of our members and debate on 23 prior Council resolutions.

This is not about furthering a political agenda but rather addressing a national public health issue. This does not need to be a partisan clash of ideals. The American College of Surgeons (ACS) recently tackled this by surveying all of its members with a robust survey method to guide their advocacy efforts and found their members agreed on much more than they disagreed on. Having objective data with high response rates will help ACEP have better direction and transparency about the current viewpoints of our members. Heaven forbid—if the surgeons can agree and make decisions without a white blood cell count or pan scan, imagine what we can do!

ACEP is composed of a politically diverse membership. The College aims to support bipartisan advocacy issues that impact emergency medicine, our patients, and our members. We don’t take sides or support “red” or “blue” issues unilaterally. We support patients, our colleagues, and our specialty. Sometimes the lines of what falls under the EM umbrella can be blurred with politically charged topics, but I believe public health and patient safety are core elements of emergency medicine, and we can find solutions and common ground if we focus on what is best for patients. That’s what we do best.

Rather than fighting over 20 percent of firearm issues where we disagree, we should be spending more time and energy moving the ball forward on the 80 percent of solutions we all agree on. The focus is not on gun control but rather preventing firearm injury. Whether you own a gun or not, we should all be on the same side here. We are industry leaders in addressing other public health issues including reducing mortality from opioids and car accidents. Investing in research, studying the impact of legislation in several states that enacted extreme risk protection orders (ERPOs), enforcing existing laws on firearm safety, and reviewing the data in the medical, economics, and criminal justice literature are objective ways we can be proactive. Studying and enforcing interventions that improve outcomes for patients is “our lane.” We need to work together, collaboratively and respectfully, to understand our differences, find common ground, and advocate for what will enhance our ability to care for our patients.

Ryan Stanton, MD, FACEP (Kentucky)

Current Professional Positions: emergency physician, Central Emergency Physicians, Lexington, Kentucky; EMS medical director, Lexington-Fayette Urban County Government; public safety medical director, Blue Grass Airport, Lexington; Kentucky and Florida medical director, AirMed International

Internships and Residency: surgery internship, James H. Quillen College of Medicine, Johnson City, Tennessee; emergency medicine residency, University of Kentucky

Medical Degree: MD, James H. Quillen College of Medicine (2003)

Response

We have so many challenges with varying degrees of divisiveness and angst among our members and leadership. Several recurring themes include diversity, guns, politics, wellness, staffing, and engaging future emergency physicians. Thankfully, I believe the majority of our members and leadership are working diligently to address many of these issues and find common ground to move forward. Bold discussions and growing diversity within our College are a couple of our greatest strengths and are working to address many of these challenging topics within emergency medicine.

However, I believe the most widespread area of divisiveness across the country specifically related to ACEP and our members is the future direction of health care with regard to politics, structure, and our role in that system. The political environment within the United States is a potential powder keg at every turn. With the history of emergency medicine and its evolution over the last number of years, we are now at a tipping point where change MUST happen. We are currently dealing with legislation regarding out-of-network billing that could cut a quarter to a third of our income and potentially impact future employment and patient access to care. The initial insurance industry–driven bill could have been devastating to our practice, allowing them to further drive down reimbursement to unsustainable levels. There are many fingers pointing to US as the problem and not the many other hands in the pockets of our patients and practices.

Emergency physicians from around the country have come together to advocate for our specialty and our patients. It is the most united I have seen our profession in quite some time. With my experience in Kentucky and Washington, D.C., during these discussions, I see the need and power of unity in emergency medicine, even if we don’t always see eye to eye.

Unfortunately, there are pretty defined lines within the political world based on right and left with special interests at every turn. That is why physicians must evolve from our historically introverted nature to become a larger and more vocal advocacy group for improved access to care, efficiency in practice, and protections allowing focus on evidence based practice. Emergency physicians must be the leaders of the house of medicine, within our departments, within our hospitals, and at all levels of policy development. We have the “best seat in the house” when it comes to the health and condition of our system and the evolving needs of our patients.

One of the greatest gifts of ACEP is the diversity of beliefs, but this also means that the debate on the direction of the health care system can be a very contentious topic. We must work together, with our primary focus, no matter the politics, being our patients and the future of our profession.

Thomas J. Sugarman, MD, FACEP (California)

Current Professional Positions: emergency physician and chair of emergency services, Sutter Delta Medical Center, Antioch, California; senior director of government affairs, Vituity, Emeryville, California; urgent care physician, East Bay Physicians Medical Group, Lafayette, California

Internships and Residency: emergency medicine residency and internship, Harbor-UCLA Medical Center

Medical Degree: MD, University of Illinois at Chicago (1989)

Response

ISSUE: ACEP’s most divisive issue is that many members and potential members perceive that partisan interests drive ACEP’s agenda. Interestingly, many of the partisanship concerns are contradictory, with some believing ACEP is biased in one direction and some seeing prejudice on the other side. Distress over partisanship manifests as a sense of anger or apathy—“it does not matter, it’s out of my control.” This limits both member engagement and ACEP membership.

Emergency physicians often have different viewpoints based on practice setting—rural vs. urban, tertiary hospital vs. referral hospital, big group vs. small group, doctor-owned v. non-doctor-owned group, or academic vs. nonacademic. Like all specialists, emergency physicians’ divergent views reflect the highly partisan national political environment that engenders political gridlock. I observe some physicians not supporting or joining ACEP because they disagree with ACEP’s position/lack of a position on a particular issue or politician. But ACEP cannot be a single-topic organization because all of our members have different single issues.

SOLUTIONS: ACEP must evaluate issues and our agenda using two principles. First, is it of primary importance to emergency physicians’ practices? Second, is the topic particular to providing emergency care rather than an interest of just some emergency physicians? If other organizations can address a problem, then ACEP should tread carefully. Since everybody is potentially an emergency patient, all issues are significant to some emergency physicians. But by focusing on concerns meeting the criteria of both directly relevant to emergency physicians and limited to emergency medicine, ACEP can be more effective. We cannot allow ACEP’s efforts to be undermined by partisanship nor distracted by issues not unique to emergency medicine.

Transparent decision making is paramount. Over the last few years, ACEP markedly improved its communication and messaging to members. ACEP redesigned its website, distributes multiple newsletters, and maintains a strong social media presence. ACEP does a great job reporting its activities and positions. Going forward, we should better explain the process, criteria, and reasoning behind our decisions. This will dispel the notion that ACEP makes partisan decisions. ACEP’s goals are to ensure emergency physician practices remain economically viable and fulfilling, allowing us to provide our patients quality emergency care.

As a member of your Board of Directors, I pledge to improve transparency so all members feel they have influence and access to the reasoning behind ACEP’s decisions. I will work for ACEP to target matters of common interest to all board-certified emergency physicians. This will improve our cohesiveness and increase membership, making ACEP more effective at representing emergency physicians’ issues.