A Brief History of the Traveling ER Doctor
It may come as a surprise to some long-time American Academy of Emergency Medicine (AAEM) members that it is embracing locum tenens in any form at all. The AAEM was formed in response to James Keaney’s book, The Rape of Emergency Medicine in 1992, which detailed a disturbing new model of emergency department staffing known as the Contract Management Group (CMG). This model commoditized physicians as a profit center for the contract owner who, at the time, was typically an emergency physician who found that profiting off of the labor of others was much more lucrative of a career than working as a physician. Today, CMGs have proliferated, merged, and have largely been acquired by Wall-Street private equity firms. These firms, while clueless about the practice of medicine, are adept at complex financial engineering, extracting value from the patients, society, and the profession of medicine.
It is necessary to acknowledge that the reputation of locum tenens physicians has in the past been spotty if not downright negative. After all, the traveling physician played an instrumental role in the metastasis of CMGs. These questionably competent mercenaries were the blood supply that assisted in the rapid CMG growth. In Dr Keaney’s book, the traveling physician, personified by the quasi-fictional character, “Monk”, was an incompetent physician shuffled around by Pyramid, Inc. so frequently that hospitals had difficulty catching on.
Traveling physicians are and continue to be a mechanism by which highly-leveraged CMGs, now desperate to pay off high-interest debt, can rapidly expand when ousting a local democratic group along with its local physicians. From “Special Ops” to “Firefighters”, CMGs cultivated well-compensated internal traveling teams to fill the gaps where contracts had been disrupted and conquered. An infamous example of this is when US Acute Care Solutions (USACS) ousted an independent group staffing Summa Health Emergency Department in Akron, Ohio and its residency under dubious circumstances. The residency lost its accreditation, leaving residents scrambling and uprooting their lives. With the contract terminated with only four days’ notice, USACS relied on its handsomely rewarded “FireFighters” team to staff the site. Dr. Allen Roberts referred to this event in his “The Rape of Emergency Medicine, 2017 version”.
So why would the AAEM endorse locum tenens in any form? The landscape in emergency medicine has continued to rapidly change. While AAEM upholds the ideal practice model as one in which physicians in a small, democratic group maintain ownership with a transparent path to partnership, this model is rare, and few independent groups remain. Market competition has markedly declined due to consolidation from payers/insurers, hospital systems, and contract management groups. This along with an increasing debt-load for the younger generation, physicians need every tool they can get.
Locum tenens has itself changed over the past decade. Once seen as a tool for washouts, money hungry sleaze bags, and social miscreants locum tenens is now being looked to by young intelligent, self empowered doctors as a way to reclaim autonomy and job craft a good life. In a world where investment banks have co-opted physician’s humanistic values for their benefit it is our chance to push back and show them that we have a voice. It is our opportunity to use the market to better medicine.
When properly informed and ethically executed, the physician can use locum tenens to regain autonomy, increase stability, and stay out from under the thumb of corporate greed in medicine.