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American Academy of Emergency Medicine

Who Cares About Due Process?

I have practiced emergency medicine since 1986 and had planned to continue to practice for another 4 years. This article was almost too personal. ABEM certification was established in 1980 with re-certification mandated every 10 years. Continuous certification was established by 2000. I am sure ABEM thought that rigorous testing would bring credibility and respect to our specialty. I cannot speak about what happens in academic centers, but I certainly can confirm that emergency physicians are the stepchildren of the hospital. It has nothing to do with competency. The medical staff is often rude, and if the right buttons are pushed by the medical staff, nursing, or administration, the ED medical director is summoned to the CEO's office.

He or she is told to dismiss the ED staff physician who has somehow attracted the anger of someone in the hospital. And the CEO holds the director hostage by threatening to terminate the contract. Thus the ED physician is abruptly terminated.

Up until the last year, if I left an ED position, it was my decision. I have been terminated four times since then, but let me elaborate. I was terminated after 4 years at a hospital in Houston when a new CEO was named. I was quite vocal about lack of equipment. We did not even have an oto-opthalamoscope in every room. The nurses were incompetent and had no clinical experience. The medical staff never came into the hospital at night when one of their patients would crash and burn. I came back to Houston at the end of a one week vacation in March and found that I was not scheduled for April. That is how much notice I received.

It isn't rocket science when an ED physician starts at a new facility, that there is a learning curve, because every hospital runs their department differently. A two week grace period to adjust was more or less accepted. The introduction of computerized medical records changed all of that.

I have been exposed to four different ED computer programs. The learning curve for each ED physician is variable. However, these programs take away valuable patient time. The expectation in my experience (and I was actually told this) is to shot gun lab and radiology. How do you know what to look for if you haven't done a thorough history and physical? The following is an example of one of my short-lived jobs: the ED director sat outside the exam room while I was working up a new patient, and timed me. My maximum time allowed was four minutes. That is a physical impossibility.

My last few jobs have lasted 4 days, 3 days, and 3 days respectively.

Can any ED physician come into a new department and reach maximum efficiency within one or two days. So much for fairness and due process. That would never happen to a staff physician. In fact, it takes an act of God to get an incompetent staff physician off staff.

I am still at the top of my game. ED physicians used to leave the profession because of burn out from shift work. Now I expect that our specialty will reach critical mass because respect by the hospital staff has reached an all-time low.

For me, the handwriting is on the wall. I can only take so many punches. If AAEM does not take a leadership role in ending a very disturbing double standard, the public will be seeing unqualified primary physicians when they are critically ill.

— Evan B. Tow, DO FAAEM


Dear Dr. Tow:

Thank you for writing. It takes courage to tell a story like yours. Unfortunately, your story is not unique — it isn’t even unusual. I promise you that AAEM is doing everything possible to assure that emergency physicians have the same due process and peer review protections as all other members of the hospital medical staff. Our progress has been slow, however, largely because so many with deep pockets want to be able to get rid of emergency physicians without any inconvenience — and because the Academy is fighting this battle with little or no help from other professional societies in emergency medicine.

Please hang in there and keep trying. You might consider an academic job or even look into nontraditional ways to practice emergency medicine, such as critical access hospitals; VA, military, or American Indian reservation hospitals; overseas practice settings; or locum tenens. There are lots of hospitals out there that are desperate for board-certified specialists in emergency medicine, and there are still hospitals and EDs that care more about quality, patient welfare, and doing the right thing than about speed and metrics.

                               — The Editor

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