Educating the Next Generation of Emergency Medicine Specialists - Dr. Mary Nan Mallory, President of the American Board of Emergency Medicine

JANNAH AMIEL: Hi, I'm Jannah Amiel, and today on Raise the Line, I'm happy to be joined by Dr. Mary Nan Mallory, Vice Dean for Clinical Affairs and Professor of Emergency Medicine at University of Louisville School of Medicine. She's also the president of the American Board of Emergency Medicine, and much of our conversations today will focus on that aspect of her professional life. Thank you so much for being with us today, Dr. Mary Nan.

DR MARY NAN MALLORY: Thank you, Jannah. It's an honor, a pleasure to be here with you. 

JANNAH AMIEL: I appreciate it. First, can we just start off by telling us a little bit about yourself and what led to your interest in emergency medicine?

DR MARY NAN MALLORY: Sure. I've often described my interest in emergency medicine as accidental tourism. I've been doing this for about 30 years now, our specialty is about forty-some years old, so we're a relatively young specialty, we're the second youngest specialty in the house of medicine.

JANNAH AMIEL: Yes.

DR MARY NAN MALLORY: And when I was in medical school, I really didn't understand much about emergency medicine. We saw students and interns and residents going down to ERs and making decisions about patients. Sometimes the least trained folks, fortunately, who were in the emergency department making decisions about patients. So, that was the exposure that I'd had, and it wasn't until I was assigned to work in an emergency department in the army because I had an HPSP army scholarship.

JANNAH AMIEL: Oh wow.

DR MARY NAN MALLORY: The army had board certified emergency physicians supervising those of us who were interns working in the emergency departments. So that was the first time I realized, wow, this is actually a job. You can make a living doing this. There's formal training, and also, you can get board certified in this specialty. So it's truly a specialty. But I was a bit perplexed the first time I saw someone's business card that said Emergency Medicine Specialist. I was like, “What is that?” Because at that point, the emergency department was where any doctor could work, and honestly at that time there weren't a lot of emergency treatments. And so maybe that was okay then, but as the science around emergency medicine has progressed, we know that we actually need specialists who understand the first hour or two of care because we have a lot of time-sensitive treatments now available, like for heart attack and stroke, et cetera.

I had quite a bit of experience on active duty with terrific, board-certified supervisors, and that inspired me after I was paying back the time I owed the army to pursue an emergency medicine residency. I matched with the program here at University of Louisville which is a very historic older program in our field, and I never left.

JANNAH AMIEL: Wow. That's awesome.

DR MARY NAN MALLORY: Yes. I went through the residency and then was invited to join the faculty, and have been here since. So essentially I've been here since 1992.

JANNAH AMIEL: Wow.

DR MARY NAN MALLORY: Yes.

JANNAH AMIEL: That's awesome. Amazing. I'm curious to learn a little bit about how you became involved with ABEM.

DR MARY NAN MALLORY: Sure. Well, that's pretty easy to answer. My mentor and chair, Dr. Dan Danzel, was very deeply involved with the idea of board certification and the American Board of Emergency Medicine very early on in his career. So when I came to residency here and I started to understand that there was a formal way to support certification, I just jumped on board. My first foray as a volunteer with the American Board of Emergency Medicine was as an oral examiner. In emergency medicine, to become board certified, our candidates, our physicians, at this point, they're physicians they've completed a residency, they have to take a qualifying written exam and then a certifying oral exam.

JANNAH AMIEL:  Oh wow.

DR MARY NAN MALLORY: And so the oral exam is like what we're doing right now, but it's more structured. And the physicians work through a case with an examiner who's had training to formally ask questions and then score their answers and their management. So it becomes all about a standard. We're setting the standard. The American Board of Emergency Medicine's mission is to ensure the highest standard in emergency medicine. And we leverage the experience and knowledge of our own board-certified emergency physicians who work all across the country in different community practices, academic practices, military practices, and urgent cares. We leverage their experience and knowledge to set the standard for our exams. That's how we perpetuate the idea of what the standard is. So, the standard is not coming from an ivory tower group of doctors, it's coming actually from the egalitarian, broad-based group of emergency medicine volunteers that serve the board.

JANNAH AMIEL:Fantastic. So I have experience working in the ED as well; I worked in the pediatric emergency room and trauma for a couple of years as a registered nurse there. As I'm reading this, I thought, “I don't know if any of the physicians I worked with were ABEM certified. I just don't know.” It's not something that was really something that we spoke a lot about, or even had a lot of knowledge about. Learning about this, I'm curious as far as patients are concerned, why is it important for patients who come into the emergency department to be cared for by physicians that are ABEM certified?

DR MARY NAN MALLORY: I think as a board certified physician, and now as a leader of an organization that supports certification and standards, it's my hope that a patient doesn't have to worry about that, right? Because we don't wear badges on our heads that say that we've had X amount of training and X amount of examinations, et cetera, we've been through multiple assessments and we passed them. Because when you're a patient and you're in distress, potentially the worst day of your life, when you have an emergency or when you're critically ill, that's certainly the last thing that any of us in healthcare want the patient to have to be worrying about, your qualifications.

JANNAH AMIEL: Right.

DR MARY NAN MALLORY: That's a big reason why I've spent a lot of time in my career volunteering for an organization that supports certification because we want patients and their family members to be assured that they are going to see an emergency physician who can stabilize them and make appropriate consultations, get them admitted, or help them with outpatient access. We want that to be seamless. And we want you to be assured. My family have been patients; I've been a patient. And so you're not going to go in on a bad day when you're in pain or you can't breathe and say, “Hey, what credentials do you have?” This is important because patients don't choose their emergency physicians. They sometimes choose their emergency departments; sometimes EMS makes that decision, or if you're a child you're taken to a children's hospital if there's one available.

JANNAH AMIEL: Right.

DR MARY NAN MALLORY: But we do have a choice in what cardiologists we see, what primary care doctor we see and we can change if we don't really like it -- usually, not all of us, because some health insurers require you to go to certain physicians. But typically even in those situations, you can change, you can request to change, but when you have an emergency you don't have that choice.

JANNAH AMIEL: Yes.

DR MARY NAN MALLORY: So there's one standard, and we really understand that every emergency department is not staffed at this point by a physician who meets that standard, and the physicians who are in those situations, I'm sure most of them do continuing certification and they try to get the education as best they can. And we're proud that they are there in those emergency departments, but having said that we really are working towards a standard for every emergency physician in every ED. That's our goal.

JANNAH AMIEL: Yes. That's important. I want to dive in a little bit to your experience in emergency department -- and that is a specialty, I absolutely agree. I'm curious, what have you recognized as the things that have changed since you started to where we are now in emergency medicine? One thing specifically that I think about is how the emergency department is used in the community, and I feel like that changes often just in small chunks of time. I would love to hear your perspective of what's different about how emergency medicine is utilized today that maybe wasn't like that when you first started.

DR MARY NAN MALLORY:  In the urban areas, I think emergency departments, especially in County hospitals were the safety net hospitals for those who were disenfranchised or too poor to have insurance. Those individuals in the community who had means had private physicians. And honestly, there weren't a lot of treatments for emergencies. So if you think about it, if someone had a stroke, there wasn't really a treatment. I was well into my career before I saw patients in emergency departments who had stroke symptoms, because most people knew they were having a stroke and they just stayed at home because there wasn't anything to do about it. So, heart attack patients, we didn't have therapies since I've been in medicine. So once we develop therapies, then we encourage patients who had those symptoms to get to the emergency department. Right?

JANNAH AMIEL: Right.

DR MARY NAN MALLORY: Typically people come to the emergency department if they can't breathe, they're in pain or something's bleeding, in general. And so what I have noticed over the years since we've moved generally in most communities away from County hospitals, and most of those hospitals have been upgraded and integrated into larger health systems, there is improved access for all patients, whether you're on the, we'll say, disenfranchised side of the railroad tracks or not. So we really elevated the care for all patients in our country. Having said that, we still are the safety net place for those who have difficulty accessing care. And there are many communities across our country, both in rural areas, as well as in urban areas, where patients have access problems, have trouble accessing a physician, and they don't understand how to call someone. And honestly, since we've moved into an era of preventative medicine, the primary care physician spends an incredible amount of time on preventative care, not very much time on acute episodic care. That responsibility now has moved to the emergency department as well. So what we've seen is more of a snowballing effect, not just the disenfranchised seeking medical care, but all patients seeking emergency care.

JANNAH AMIEL: Yeah. That's fantastic. So we've got to get into COVID.

DR MARY NAN MALLORY: Okay.

JANNAH AMIEL: Because COVID has gotten into, I want COVID to get out of us.

DR MARY NAN MALLORY: Yes.

JANNAH AMIEL: No kidding. As the front frontline, we hear “frontline, frontline, frontline,” of course I immediately think of all my nursing peers. I think of all my physician teammates. I think of everybody who right now is caring for patients and is feeling it in a way that we haven't felt in a really long time. I'm curious about emergency medicine specialists – physicians like yourself that are working in the ED during this time in the COVID crisis. And one thing that, when I think about burnout and I think about frontlines, I think about that. What are your concerns there? Are you concerned that we're going to be seeing big levels of burnout in physicians in the emergency department? And what does that look like when we're on the other end of this?

DR MARY NAN MALLORY: Well, we're definitely seeing it. I'm hearing about it from colleagues in some communities. This week I talked to a group of emergency physicians from New York Presbyterian, over in Brooklyn. We were reminiscing about some of the challenges that they faced earlier on in the pandemic and how disappointed they were that other communities didn't learn from their experience. What I was able to see is they are recovering.

JANNAH AMIEL: Yes.

DR MARY NAN MALLORY: So, I'm optimistic that we will recover, but there are battle scars, and there are some, unfortunately, some fatalities here.

JANNAH AMIEL: Yes.

DR MARY NAN MALLORY: We've had some high-profile emergency physician suicides acknowledged in our country, emergency medicine itself with the various shift work and the stressors, of meeting and greeting and caring for people on the worst day of their life, pretty much every shift. It's a stressful profession to begin with. And we train each other on techniques and strategies to maintain our health, but this has been a tipping point. This pandemic has presented a tipping point for emergency physicians as it has for nurses as well and our family members. We were fearful, I think more in the beginning because we didn't understand the ramifications of the disease for our own families, and so many physicians separated from their families while they were caring for a lot of COVID patients. But as time has gone on, I think we have a better understanding; I think we're gaining control. We're back, taking a breath, we generally have PPE. We are understanding how to better treat patients with COVID, and we are getting more treatments, and the vaccine is upon us. So I think we're moving back into some equilibrium, catching our breath. And the next six to nine months – we are a resilient crowd.

JANNAH AMIEL: That's for sure.

DR MARY NAN MALLORY: We're a resilient crowd, Jannah. We wouldn't be in this specialty if we weren't resilient. This time next year, not that there won't be some casualties, I think we'll be in a much better position professionally. Before we get off that topic though, I should mention that all of our professional societies, as well as many of our health systems have reached out to their members, their physicians, their nurses, with counselors, mental health, 24 hour calls. Sometimes it's just something as simple though as peer to peer debrief. We take each other aside with our masks on, six or twelve feet apart, and we just, we might cry or we might talk about what just happened, how unfair it was, because sometimes we're the ones standing by when no family can be here. Particularly our nurses, because they are caring comfort folks.

I've often been told that I'm a great physician, but I'm a terrible nurse because, if I was in a clinical environment I probably don't get the best check marks for compassion because I'm trying to get things done. And so we have to acknowledge as a team in the emergency department, we all have a role to play and we've got to support each other in those roles in times like this.

JANNAH AMIEL: I agree. I think that's perfectly said. And one of the things that I feel was really revealed as a result of what we're dealing with now in the pandemic, I guess it's an opportunity to step back and think about what are the things we need to do better when we do get on the other side of this. That burnout and the fatigue and the mental wellness is something that we've always talked about. We've had that when we talk about healthcare and frontline workers; it's become something in my eyes and in my opinion now that I feel like people are really paying attention to, and now we're taking that quite seriously.

What are some things for you, that you might feel like now during this time we've seen these revelations in our healthcare systems, perhaps gaps in our healthcare and how we deliver that? What are the things that you feel we can do better to strengthen it so when we do come out on the other end of this, we've learned? We've taken the lessons and we've learned. How do we do that? What does that look like?

DR MARY NAN MALLORY: Well, something we haven't really talked about a lot yet, the healthcare disparities that this pandemic has shown a bright light upon. And as I mentioned in emergency medicine, we have been managing through that one patient at a time for many years. But as our specialty has matured we find emergency physicians more actively involved in public health. In my small region here there are two emergency positions who are leading the public health initiatives in their counties, just for an example. We have an emergency physician in our community who's the CMO and vice president of a health system. And I'm Vice Dean for Clinical Affairs and I work with our practice plan and our health systems, as well as with all the health systems in our community. And we really get that. We know it in our heart, we know it in our minds. We see it.

The challenge is when we don't have patients coming in our doors as quickly with this disease, then it's going to be a shame on all of us if we haven't made some action around reaching down and around, and over, and through, and solving some of these problems, putting some real resources and real systems change around these problems. So, that's one area. Another area as you mentioned is healthcare provider mental health and also community mental health. And so I think we're going to see more structured ways in the medical community that we care for each other in terms of mental health, and stress is an easy word to say, I think everyone I know has anxiety, but there are some serious mental health problems: depression, suicidality, completed suicide. And I think we're going to see ourselves as physicians and healthcare providers addressing that more openly and more deliberately, to go forward.

The other thing that I think is really cool is that one of the reasons I loved emergency medicine is it's a team sport. And when I was starting in emergency medicine, it was clearly a team sport, and there was a lot of support between nursing staff and techs and high-fiving and encouragement and education up and down that chain, so to speak, if you think of it as a hierarchical chain where the physician is the leader. Probably the last ten years we've moved away from that, once we got electronic health records. Everybody in the ED is trying to do their get. They've got to get their notes in and they've got to type and everyone's looking at a screen, and we didn't go into medicine, none of us went into medicine to look at screens on computers.

And this pandemic, I think has brought the professions together in a way that I haven't seen since the advent of electronic health records, I don't want to bash electronic health records, it used to take me hours to get an old EKG, so I think chest pain situation. So it changed our flow and it changed our interpersonal interactions, and I think we've gotten better again at communicating with each other as providers, leveraging that, those digital innovations, and also better at communicating and caring for patients.

JANNAH AMIEL: Yes.

DR MARY NAN MALLORY: So those are my top three. We can talk next year and see if we're on our way.

JANNAH AMIEL: Right. If we're on track or not.

DR MARY NAN MALLORY: That's right.

JANNAH AMIEL: Those were some really great points. I think the caring has definitely become more deliberate and less of a word that we say. We think about it and it feels good. And yes, those EMRs, they're necessary, I get it, but yes. When it's 7:00 PM and you're scrambling to chart everything, conversation with real people, connecting with real people, just having that dialogue is out the window. And I think that you're right. That changes the dynamic and it changes the way that we even present ourselves to patients and communicate with them. That's a fantastic point. So in our audience, we have a lot of students and early healthcare professionals that listen in to these podcasts. What would be your advice to them about meeting the challenges of this moment and approaching their career in healthcare?

DR MARY NAN MALLORY: Wow. Well, the first thing that occurs to me is this is your time, especially if you're early in your career, it's all a bit much perhaps, but this is your time. Every time we've had physical wars, the army medical department, for example, or the civilian medical community have made great advances that have been scaled or modified for other areas in medicine to advance the care of our patients. So in some ways I think students learners right now feel disenfranchised, because at the beginning of the pandemic for their own safety and to preserve PPE, they were removed from the clinical environment, right? So, that's been a challenge. Some of our institutions used video technology in order to try to keep students connected. So leveraging technology in order to teach and learn in a new way came out of the pandemic, at least in some of our academic centers.

But if I was a student, what I hear from our own students, they're concerned about the social challenges, the social unrest, the social issues, the diversity and inequity challenges that they see in society. It's their coming of age, right? They're feeling that stress of coming of age at the same time they're learning medicine. So I think a piece of advice is while you can't be untrue to yourself and your beliefs, you've got to focus on the medicine, you spent so much time getting here into this learning environment, and you've got to, hopefully you're committed still to complete the task and become the very best student and physician that you can be. We need that, because there's a lot of folks that can protest and politic, but you're very unique and gifted in the areas of science and study and clinical reasoning. And so please focus, please focus.

And one of the ways that you can stay connected, or improve your connectivity with your physician peers, mentors, leaders, almost every professional society in medicine, I know in emergency medicine, has remote mentorship available for students. So sometimes that means you're just exploring the specialty. Sometimes that means you're a resident and you have an offsite mentor. Your program leadership doesn't even need to know you have this mentor. Again, in the digital age, there are so many more opportunities to reach out digitally, to not only learn clinical medicine at your institution, but to obtain mentorship. And most all of us in academics, we love to talk, we love to teach, we love to hear ourselves talk, blah, blah, blah. Also, to the degree that you can shadow, get into some shadowing experiences. I think most health systems are now allowing students to reintegrate and reenter. And you may need to take a little extra time on your own to shadow in an emergency department, or shadow in an operating room, away from your actual clinical or basic science education.

So I do think there's going to be a little makeup time that students are going to need to take responsibility for and lean in, in that regard. It is what it is. You didn't wind up overseas. My dean, Toni Ganzel, she's an amazing woman. She became dean through the student affairs track, at the medical school. So she really understands students and their challenges. When she faces challenges, she walks into the lobby in front of her office and she stands in front of one of our previous dean's portraits. And down on the bottom, underneath that portrait, there's a short inscription that says that he was the dean of the medical school when a hundred percent of his students were in uniform and deployed overseas.

It's like, what did that mean for them? Right? In World War II, when they were all gone, they weren't even here. They were deployed overseas to act as physicians in training. We haven't required or asked that of our medical students. Right? You're home, and in some cases in difficult situations, we certainly understand that, but you have this opportunity to continue to be learning, and we want you to keep leaning in because it's so important. Your education is critically important to you and the patients you're going to serve, which may be me, right? Or my family, or your own family, et cetera, et cetera. So I want you to remain optimistic. We're all going to get through this.

JANNAH AMIEL: That's awesome. That's fantastic advice. Very motivational and inspiring. It's easy to feel like, I don't know if this is the right time, but you're right. The time is now.

DR MARY NAN MALLORY: Right. The time is now. Lean into your education, and it's as if you were serving in World War II, you're at home, whatever that means. I know it's not optimal, but  you're not in a field hospital in the middle of Europe. I'm not trying to balance that and say, “Oh, we have it so much better.” I'm just trying to say lean in and control what you can control. And keep learning and keep communicating, keep reaching out, because we're here. The educators are here, we're still here and we're still committed to you.

JANNAH AMIEL: Hundred percent. That's fantastic. Dr. Mary Nan Mallory, thank you so much for being with us today.

DR MARY NAN MALLORY: It's been my pleasure.

JANNAH AMIEL: I appreciate it. You've really shared some gems with us. I'm Jannah Amiel. Thanks for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together.