Development of a Focused Designation of Clinical Practice in Ultrasound
Authors: Melissa Myers, MD FAAEM and Alexis Salerno, MD
Emergency physicians have been an essential part of the development of Point-of-Care Ultrasound (POCUS). In the 1970s, POCUS started as part of the trauma resuscitation. Since then, emergency physicians have expanded the boundaries of POCUS to evaluate and treat a wide range of medical conditions. As early as 1988, emergency physicians began publishing on the use of bedside ultrasound in the emergency department. Within a few years, in 1991, both the American College of Emergency Physicians (ACEP) and the Society of Academic Emergency Medicine (SAEM) published policy statements regarding the utility of bedside ultrasound in the emergency department.1
Emergency physicians have also led the way in developing curriculum. The first published curriculum in 1994 by Mateer et al has led to multiple well-developed curriculums based in educational research. Today, POCUS is considered an essential skill and was recognized as such in the 2013 Model of the Clinical Practice of Emergency Medicine. Modern emergency medicine residencies include rigorous and extensive training in POCUS with graduates performing a wide array of POCUS skills to diagnosis and treat their patients.
Some emergency physicians choose to pursue ultrasound training beyond that required during residency, by completing an emergency ultrasound fellowship. During one or two year fellowships, these physicians become experts in advanced ultrasound modalities and ultrasound education. The presence of ultrasound fellowship trained faculty at residency sites correlates with a higher number of faculty credentialed to perform ultrasound and may assist with quality assurance for ultrasound performed in the ED.2 Fellowship trained emergency physicians also continue to develop new ways to improve the use of POCUS and to study best practices for use on shift.
The Society for Clinical Ultrasound Fellowships (SCUF) currently lists 50 fellowships, though this list is not exhaustive, and does not include the military programs. Until recently, there has been no established way to recognize physicians who choose to pursue this extra training or to credential these fellowships. While some have chosen to pursue recognition through the exams offered by the American Registry for Diagnostic Medical Sonography or other similar organizations, these exams were not developed by emergency physicians and do not reflect the use of POCUS in the emergency department. As noted by Dr. Gibbons in the May/June 2019 edition of Common Sense, emergency physicians do not need these merit badges to legitimize our training.3
Following an extended debate and vote, members of these fellowships and ultrasound societies nationwide felt that attempting to establish a subspecialty board could have unintended consequences for the practice of POCUS by those who did not choose to pursue a fellowship. The alternative chosen was a “Focused Practice Designation (FPD).”
The FPD, which is approved by the American Board of Medical Specialties, “recognizes physicians who devote a substantial portion of their practice to a specific area of a specialty.”4 This will hope to recognize emergency physicians with expertise in emergency ultrasound beyond the requirements for ABEM certification. It will be a recognition developed by emergency physicians which will be specific to the requirements of our specialty. There will be three pathways to obtain this designation, the fellowship training pathway, the training-plus-practice, and the practice-only pathway.5
In the fellowship training pathway, physicians will complete an Advanced Emergency Medicine Ultrasound (AEMUS) fellowship accredited by the Emergency Ultrasound Fellowship Accreditation Council (EUFAC). The Society of Clinical Ultrasound Fellowships (SCUF) will be charged with the creation of this council. For those who do not know, the current SCUF website helps potential fellows compare various ultrasound fellowships and complete fellowship applications. In the future, the EUFAC will release regulations to obtain fellowship accreditation and a curriculum for the fellows. The curriculum will expand on the basic emergency medicine ultrasound knowledge by including advanced measurements and views. Although the curriculum has not been released yet, potential topics may include muscular tendon assessment, arterial doppler assessment or even cardiac diastology. The curriculum will most likely also cover administrative topics such as billing and workflow solutions.
In the training-plus-practice pathway, physicians must complete an acceptable non-EUFAC accredited fellowship. This pathway will most likely be for recent emergency ultrasound fellows who graduated prior to the date of the first accredited fellowship. The physician must also demonstrate 24 months of AEMUS practice including performing or supervising 300 studies per year and reviewing for quality assurance 500 studies per year. This pathway will only be available to physicians for five years from the date of the first EUFAC-accredited AEMUS fellowship. Those who are considering applying for this pathway, may wish to start logging ultrasound scans and QA’ed studies.
In the practice-only pathway, physicians must demonstrate 36 months of AEMUS practice with 300 performed or supervised studies and 500 reviewed studies. In addition, physicians will have to demonstrate additional knowledge in the area by prior work in leadership administration, publications, or teaching. This pathway will most likely be for more senior faculty that continue to have a strong interest in ultrasound. And just as in the training-plus-practice pathway, this will only be available to physicians for five years from the date of the first EUFAC-accredited AEMUS fellowship.
Physicians who meet the eligibility criteria will also need an appropriate verifier who can confirm the physician has the hand-eye-motor coordination to perform ultrasound tasks. Finally, physicians will be able to take a multiple-choice examination to gain FPD. The first exam is scheduled to be offered in 2022.
Through these pathways, emergency physicians who devoted significant time and attention to practicing point-of-care ultrasound will be able to obtain recognition of their expertise. This exciting development will likely continue to evolve over the next few years as ultrasound societies nationwide work together to develop the exam and fellowship credentialing guidelines. To keep updated on the progress of the AEMUS FPD check out the SCUF website at eusfellowships.com and don’t forget to check out EUS-AAEM newsletter, the POCUS Report.
- Kendall, J. L., Hoffenberg, S. R., & Smith, R. S. (2007). History of emergency and critical care ultrasound: the evolution of a new imaging paradigm. Critical care medicine, 35(5), S126-S130.
- Das, D., Kapoor, M., Brown, C., Ndubuisi, A., & Gupta, S. (2016). Current status of emergency department attending physician ultrasound credentialing and quality assurance in the United States. Critical ultrasound journal, 8(1), 6.
- Gibbons, Ryan. “Emergency Ultrasound Merit Badges...There’s No Need.” Common Sense, May/June 2019.
- Focused Practice Designation. Focused Practice Designation | American Board of Medical Specialties. https://www.abms.org/board-certification/focused-practice-designation/. Accessed August 18, 2019.
- Advanced EM Ultrasonography. American Board of Emergency Medicine. https://www.abem.org/public/become-certified/focused-practice-designation/advanced-em-ultrasonography. Accessed August 18, 2019.
Queuing Patients in the Emergency Department: Can It Work?
Issue: September/October 2019
Authors: Andrea Blome, MD
What is queuing theory?
Queuing theory originated more than a century ago from the study of telephone delays and congestion. A simple queue is defined by a stream of arriving customers or tasks that are handled by a server. The goal of queuing models is to eliminate the disparity between the demand for service and the capacity to meet that demand. The concept is used in many service industries to strategize how to improve efficiency.1 For instance, a grocery store that struggles with long lines for check-out could add an express lane for customers with smaller amounts of items to reduce waiting time overall. In addition, call centers for customer service have used technology to improve caller wait times with the ‘virtual queue,’ which keeps the caller in line, but calls the customer back when the agent is free.2
How does it work in the ED?
In the emergency department (ED), decreasing patient wait times is vital. Increased wait times lead to delayed diagnosis, poor patient satisfaction, and increased morbidity and mortality. The ED can be simplified to a ‘multiple server, single phase’ queue, in which patients wait in one line (the waiting room) for servers, including the triage nurse, the bedside nurse, and the physician.3
In health care, queuing calculations are generally based on patient arrival rate, service rate (time for exam, tests, treatment), and the number of servers (number of providers and ancillary staff).4 Most models use the Poisson arrival process, which assumes patients arrive according to a random process. Arrival and service times can vary based on the time of day, the season, etc.1
In the ED queue, interventions should focus on either reducing the server utilization or reducing variation. To reduce server utilization, the rate of service can be increased, with the goal of identifying wasteful elements and reducing or eliminating them. To reduce variation in service, the alignment of the staffing should first match demand before adding additional servers to the system. By predicting the average distribution of patient arrivals by hour, the staffing model can be adjusted to have more servers during high demand times.1 To reduce variation, the variation in arrival and/or the variation in service should be decreased. Reducing variation in arrivals can be difficult, as not much can be done to impact the timing of emergencies. Variation in service is usually related to issues of process, layout, supplies, equipment, and supporting services. For instance, a laceration repair might take longer if supplies are not readily available and stocked in the room where the procedure is being done. Even small adjustments to these issues can reduce service variation.1
Figure 1: Opportunities to Reduce Variation5
Can it work?
Queuing theory can be used to predict the effect of patient arrivals, treatment time, and ED boarding on the patients who leave without being seen (LWBS). One institution used a queuing model to analyze the ED flow model currently in place and found that a queuing model was able to predict the variation in patients who LWBS.6
Lehigh Valley Health Network in Pennsylvania took the theory one step further. The institution used a queuing model to identify that the ED was understaffed during peak hours and overstaffed during non-peak hours. After aligning resource capacity with hourly demand, the hospital saw a reduction of length of stay by 20% and reduced walk-out rates by 58%.5
Figure 2: How to Implement Queuing in the Emergency Department
ED’s are complex, especially in large, academic teaching hospitals. Relying solely on averages to determine forecasts can certainly affect the model. Accounting for residents and medical students in the formula can also impact predicted outcomes. However, queuing models can and should be considered in ED’s in order to improve efficiency and decrease wait times.
1 Crane, Jody, and Noon, Chuck. “The Definitive Guide to Emergency Department Operational Improvement.” CRC Press, 2011, (119-145).
2 Kulbyte, Toma. “5 ways to manage (and reduce) your customer service queues.” November, 2018. https://www.superoffice.com/blog/customer-service-queues/.
3 “Introduction to Queuing Theory.” What is Six Sigma? https://www.whatissixsigma.net/queueing-theory-introduction/.
4 Chowdhury, Naser, et al. “Using Queuing Theory to Reduce Wait, Stay in Emergency Department.” Sept 2018. https://www.physicianleaders.org/news/queuing-theory-reducing-wait-stay.
5 Hu, Xia, et al. “Applying queueing theory to the study of emergency department operations: a survey and a discussion of comparable simulation studies.” Intl. Trans. in Op. Res. 25 (2018) 7–49 DOI: 10.1111/itor.12400.
6 Wiler, JL, et al. “An emergency department patient flow model based on queueing theory principles.” Acad Emerg Med. 2013 Sep;20(9):939-46. doi: 10.1111/acem.12215.
A Sad But True Story
Issue: July/August 2019
Authors: Andy Mayer, MD FAAEM
The issue of the appropriate role of advanced practice providers (APPs) in our emergency departments has been recently analyzed by a task force of AAEM and a new position statement has been approved. AAEM recently published this position statement and AAEM and this editor also submitted contributions to other emergency medicine publications (EM News, April, 2019) related to this issue. Common Sense has recently been contacted by a member of AAEM related to the impact of the increasing use and role of mid-levels in our emergency departments.
This member has recently been told by the new contract management company which took over her hospital’s emergency department staffing contract that there would no longer be any shifts available for her and the other part-time physicians, as the company would be bringing in midlevel providers to take these shifts. Common Sense thought an interview with her would be a good way for our members to understand the risks to our practices by the expanded use of midlevels. Will we be replaced by Doctors of Nursing Practice (DNPs)?
Andy Mayer, MD FAAEM
Editor, Common Sense
Dr. Mayer: So, please tell us a little about yourself, where you went to school, your path to emergency medicine and training.
MEMBER: I am an emergency physician in Louisiana. I went to LSU Medical School in New Orleans, and originally wanted to be a pediatrician. During my third year of pediatric residency, I did a rotation in a pediatric ED and loved it. It was then that I decided to do EM. My initial plan was to do Peds EM, but when I did a second residency in emergency medicine, I found out that I really like adults too!
Dr. Mayer: How did you end up in in practice in Louisiana?
MEMBER: I am from Louisiana and I decided to stay home to be around my family after residency. My first real job was with my current hospital system, and have been with them for around 15 years (other than a brief time at another local hospital to help them start their pediatric ED).
Dr. Mayer: Tell us about the group you joined and the working conditions.
MEMBER: The physician group here has been great to be a part of for many years. It really has been a family-type of atmosphere. We have over 30 ED physicians, and have been providing good care in our region. In fact, we are the only hospital in our area with all board certified emergency physicians working in our emergency departments. I went to parttime work when my daughter was in kindergarten, and she is in 4th grade now. I was an older mom, and wanted to enjoy being a mom. I could be flexible and work more when there was a need and could work less when needed less. Interestingly as a side note, part-time work has been advocated as one avenue to help physician burnout, and I agree. Being part-time has helped me enjoy work more.
Dr. Mayer: Your group sounded great and a place many of us would have been proud to work with. Please tell us what happened? How did the changes to your group by the new contract holder affect you and the other board certified emergency physicians working there?
MEMBER: The hospital was in the process of rolling out a new contract for the ED physicians. In fact, I had just signed the new contract two weeks before that day in August when we were told on a group text that an outside contract management group would be taking over our contract effective November 1. We were blindsided. It was a surprise even to the directors. The corporate management group said that the pay would not change significantly. They gave the staff information on new changes in March.
One change they planned on implementing was to bring on advanced practice providers. Board certified emergency physician hours would be decreased to make room for these midlevel providers. I was told that this was because the labor cost for these midlevel providers was cheaper. This meant that the part-time doctors would no longer be needed as their shifts would be filled with the midlevels, and many of the full-time doctors would have their hours cut. We were all board certified emergency physicians, most with 19+ years of experience. One has been a loyal ED doctor in our system for almost 40 years. Many of us are doctor moms (who work full-time at home, too). Others are also employed at our VA hospital and supplement their income for their families with part-time shifts at our hospital. No more work for us in the hospital system we have been serving for years. We will not be needed, as non-doctors will be replacing us on the schedule.
My residency advisor, who is now one of the administrators at the CMG, had to tell me in April (ironically the day after Doctor’s Day) that there will not be any more shifts for me or the other part-time doctors when the APPs will be implemented. I told her that it stinks. She said it was business. So emergency medicine is just down to business now. How will patient care suffer? I do understand the business part, but replacing doctors with non-doctors is not right. Also, the physicians who remain with the system will be required to work with APPs. It would be different if you have
a midlevel provider in an office setting, where you can hire and train them to work as you do. However, in the ED there are so many different doctors
to work with and different individual approaches to patient care. The ED doc has no voice in whom to hire or who they will work with on shift. They can be required to work with them even if they would have treated a patient differently, and this opens the physician up to more risk of litigation. True point, there are now malpractice lawsuits where this has happened and the doctor was sued — and lost.
Dr. Mayer: Where are you working now?
MEMBER: I still love emergency medicine. I am blessed to be in a field where I can work on a part-time basis. I have been working some at our
VA and in rural emergency departments lately. The work is good, and I have time to talk and visit with my patients. For Doctor’s Day, the rural hospital gave all the docs a nice engraved mug with candy. (I was told that even the pharmacists were involved in helping with the Doctor’s Day gifts!) That is definitely a different experience. Yes, there is a physician shortage in the rural areas. Part of the solution was to have midlevel providers in these areas. Weren’t they originally started as an entity to help doctors, not to replace them? Ironically, they are taking my job in the city, and now I drive out to the rural areas to work.
Dr. Mayer: Tell us what you are looking for and what message you have for your fellow emergency physicians in this changing work environment.
MEMBER: Please know that there are many advanced practice providers who I think are excellent — and they can be of great assistance to doctors in many fields. However, I do not think they should take the place of a board certified physician in the ED just because they are less expensive labor. Less expensive does not always equal similar quality. Would construction companies stop using steel to make buildings because it is too expensive? They might use aluminum because it is cheaper, and looks the same, but there will be detrimental long-term effects.
I have contacted ACEP and AAEM — it would be great if our societies could work together on this issue. Do board certified emergency physicians want full independent practice for advanced practice providers at the risk of making ourselves obsolete and diminishing patient care? If we can be replaced by a nurse with an online degree what message would that send to the medical students and emergency medicine residents who are spending years and huge sums of money to reach the goal of board certification? Does this mean that our training is not that important during medical school and residency? Do the number of hours required to become a midlevel compare in any way to the sacrifices required to become an actual emergency physician? The depth of knowledge is not the same. The recent exponential rise of online NP programs with their clinical hours of shadowing doctors should not replace the years of clinical training and experience of a physician, but it has. They use our education and board certification and dilute its value. How can I recommend to my pre-med niece to be an emergency physician, when we are so easily replaceable? Also, how could it be recommended to be ABEM board certified, to jump through all of the hoops we have to, like MOC, when someone who has DONE NONE OF THIS can take your job?
My message to our ED docs is this — we need to be proactive with our contracts because our jobs and patient care are at stake. We might talk to our anesthesia colleagues, as they have been working against full independent practice of their APPs/CRNAs for years before us. We need for the public to be aware of this shift in medical care so they can have a voice in who treats them in the ED. We could refuse to cosign charts of patients we have not been consulted on, or chart a disclaimer that the patient was not independently evaluated by the MD while they were in the ED. We need for ACEP and AAEM to help speak for physicians who are afraid to do so on this issue for fear of job loss. The contract management groups have become too powerful, but we also need to realize this is not just a CMG problem. It is also going on in academic centers, hospital based departments, and smaller partnership groups. We also need to become more business oriented, maybe depending less on CMGs and more on working together with administration to form our own groups. I understand that it is a business, but our patients should be the first priority. In a post from April, Dr. Edwin Leap talked about things we can do as physicians to improve our situation and satisfaction. He said, “I hope that over time we can push back, steadily, against bad ideas. ...To start by calling them out in the light so that physicians aren’t bullied into thinking that they’re alone, or that they’re complainers. Shine the light on the demons and they scatter. And look smaller than we thought when we stand together.”
In Louisiana, we love our Saints football. To use a football analogy, we don’t need another blown call while those with the power to change things look away and say “It’s not my problem.” This is a blown call for patient care in the ED. Our founding EM physicians fought hard to make our specialty separate and valuable for patients in emergency situations, not to give our specialty away to the lowest bidder. Job security is a thing of the past.
The really sad truth of this whole story is the courage it took for this emergency physician to come forward to share her story. When did we subjugate the
practice of medicine to corporate management groups and hospital administrators? There are many emergency physicians who have been adversely affected by the increasing role of mid-levels working in our nation’s emergency departments. AAEM cares about this issue and wants to hear your story. AAEM has created a form where you can submit ways the increasing role of advanced practice providers has affected you. We want to hear your stories and we understand if you want to be anonymous. The fear of retribution by CMG’s and the like is sadly a real and increasingly oppressive force in modern emergency medicine. AAEM wants to clarify the role of mid-levels in our emergency departments and support the practice of emergency medicine led and controlled by board certified emergency physicians. Please submit a concern or send a letter or comment to the editor. Submit a concern here: https://www.aaem.org/get-involved/committees/committee-groups/em-workforce.
— Andy Mayer, MD FAAEM
Editor, Common Sense
Getting Off the Ground: Developing an ED Patient and Family Advocacy Council to Improve Patient Experience
Issue: May/June 2019
Authors: Jonathan D. Sonis, MD; Maryfran Hughes, RN MSN NE-BC; Cassie Kraus; Robin Lipkis-Orlando, RN MS NE-BC; Linda Kane, MSW LCSW; Benjamin White, MD FAAEM
Patient experience continues to be a growing area of focus for hospital and emergency department (ED) leaders across the United States.1, 2 Despite this, existing avenues of obtaining accurate data regarding the most critical drivers of ED patient experience are limited and, importantly, largely missing the perspective of patients and family members themselves.3 While many U.S. EDs employ a postvisit survey tool (i.e., Press Ganey, Healthstream, QDM, and others), survey data may be limited by poor response rates, non-response bias, and restricted by the scope of the responses reported.4
To address the critical need for patient and family member input in improving patient experience, Patient and Family Advocacy Councils (PFACs), which include both invited patients and family members and selected staff, have been employed at the hospital and specialty level with increasing frequency over the past decade. In early 2018, recognizing a void of the patient’s voice in our own ED patient experience improvement efforts, we set out to create the first-ever ED PFAC at Massachusetts General Hospital.
Planning and Staff Recruitment
The first step in developing the ED PFAC was ensuring that stakeholders from all branches of the department’s leadership were supportive of the concept and would be willing to devote time and resources to the project. Early on, the ED Nursing Director, ED Clinical Director, and Executive Director all recognized the value in forming such a council and agreed to participate. Given the need for experience with PFAC formation, we also reached out to and gained the support of the director of our hospital’s Office of Patient Advocacy (OPA), who provided not only invaluable expertise and support, but also a source of potential participants.
To create balance within the group, it was decided that the PFAC would be co-chaired by a nurse (ED Nursing Director) and a physician (ED Administrative Fellow) with plans to also include a representative from ED Administration (Administrative Manager for Quality and Process Improvement) and the OPA (Advocacy Representative), as well as the ED Clinical Director.
Patient and Family Recruitment
Based on recommendations from the OPA, we sought to have an approximate one-to-one ratio of patients and family participants to staff participants in our PFAC. Therefore, five patient and family participants were sought out. Three participants were identified by the OPA as they had expressed interest in joining a PFAC and had experienced several episodes of care in the ED. Another two participants were identified directly by the PFAC co-chairs through communication following ED visits. Finally, a sixth patient participant who had already expressed long-term interest in supporting ED patient experience improvement efforts was asked to join the group. All participants were interviewed prior to being selected to participate on the council.
First Meeting Logistics
An initial meeting was scheduled for January 2019 after consulting the schedules of each participant. The agenda for the initial PFAC meeting was developed by the co-chairs with assistance and feedback from the OPA with the goal of introducing all participants and providing a general “lay of the land” of the major challenges facing our ED as well as existing solutions. This included a brief explanation of the PFAC’s development and the importance of patient and family perspective in improving ED patient experience followed by participant introductions, a brief summary of ED statistics and a demonstration of previous and current patient experience improvement efforts. While a formal agenda was utilized, extensive discussion among participants occurred throughout the meeting.
A key challenge throughout the planning and recruitment process was ensuring that the resulting group was diverse and as representative as possible of the population served by our ED. In particular, we found it more difficult to recruit younger participants than retirees, who often expressed increased time flexibility compared to their working counterparts. Ongoing recruitment efforts will focus particularly on underrepresented groups.
An additional challenge revolved around management of the meeting itself. Because all participants were eager to share their experiences and personal interests, some group members were more vocal throughout, at times making it challenging for others’ voices to be expressed. Moving forward, each meeting will begin with a summary of meeting expectations, including adhering to time limits and avoiding interruption.
Lastly, maintaining momentum and enthusiasm throughout the PFAC group will continue to be a challenge, both for patient and family participants and for staff. We plan to schedule meetings quarterly for the first year in order to continue to build momentum, with the option of decreasing frequency to three times annually in the second year.
While it is too early to determine whether the formation of the ED PFAC will lead to quantitative improvement in ED patient experience, initial feedback has been universally positive, with patients, family members, staff, and departmental leadership enthusiastic about the promise of gaining the patient and family member perspective in our ongoing patient experience efforts. Despite the challenges in providing excellence in patient experience in the ED, this relatively low-effort, low-resource project has the potential to bring significant and longstanding improvement for our patients and their families.6-8
1. Emergency Department Patient Experiences with Care (EDPEC) Survey. Accessed via: https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/ed.html, January 2019.
2. HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems. Accessed via: http://www.hcahpsonline.org/, January 2019.
3. Working with patient and families as advisors (Implementation Handbook). Agency for Healthcare Research and Quality. Accessed via: https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Implement_Hndbook_508_v2.pdf, January 2019.
4. Tyser AR et al. Evidence of non-response bias in the Press-Ganey patient satisfaction survey. BMC Health Serv Res. 2016 Aug 4;16.
5. Massachusetts General Hospital 2017-18 Patient and Family Advisory Council Annual Report. Accessed via: https://www.massgeneral.org/patientadvisorycouncils/assets/pdf/2017-18-massgeneral-pfac-annualreport.pdf, January 2019.
6. Welch SJ. Twenty years of patient satisfaction research applied to the emergency department: a qualitative review. Am J Med Qual. 2010;25(1):64-72.
7. Pines JM, Iyer S, Disbot M, Hollander JE, Shofer FS, Datner EM. The effect of emergency department crowding on patient satisfaction for admitted patients. Acad Emerg Med. 2008;15(9):825-831.
8. Taylor C, Benger JR. Patient satisfaction in emergency medicine. Emerg Med J. 2004;21(5):528-532.
Why Did AAEM Take a Stand Against APP Independent Practice?
Physician members of the American Academy of Emergency Medicine have voiced concerns about the use of advanced practice providers (APPs) in the emergency department and their push for independent practice without the supervision or even availability of a physician. The task force spent hours discussing the issues, comparing the education of physician assistants, nurse practitioners, and board-certified emergency physicians, speaking to physicians about their concerns, and examining the literature. (J Emerg Med 2004;26:279; Acad Emerg Med 2002;9:1452; J Emerg Med 1999;17:427; Acad Emerg Med 1998;5:247; Ann Emerg Med 1992;21:528.)
Most emergency physicians have worked with APPs and appreciate that they are talented clinicians who improve emergency department flow, efficiency, and quality of care under the guidance of the emergency physician-led team. Many emergency physicians are aware of situations that place APPs in clinical environments that are beyond their capabilities, level of training, and even scope of practice. This is not the quality of care our emergency patients deserve.
There is a vast difference in the clinical training of APPs compared with EPs. Some APP training programs require only 500 hours of unregulated, supervised clinical experience before graduating, while physicians must complete approximately 4,000 hours of clinical experience during medical school and an additional 8500 hours of highly regulated and supervised training as an emergency medicine resident before entering independent clinical practice. (J Emerg Med 2015;48:474.)
APPs do have a valuable role in many emergency departments, but their skills should be used as part of a team led by an ABEM/AOBEM emergency physician. APPs as members of that team should fill a role clearly defined by the emergency physicians in that department which professionally stimulates the APP and results in quality care. The cost of employment is lower for APPs than for EPs. As increasing patient volume drives increased need for coverage, the potential for increased profits grows if APPs replace EPs. The delivery of safe, expert physician-led care to every patient must be the primary factor when making staffing decisions, not profit.
The physicians staffing an emergency department are best capable of determining the needs of their department. Physicians should not be told by management that they must use APPs who have been hired for them. Rather, they should decide how many APPs they need and hire only those candidates who have the expertise and personality to mesh well with the culture of their emergency department team.
We are aware of situations where EPs are expected to supervise three, four, or even five APPs while simultaneously seeing patients primarily. The reality of those situations is often that the EP has only a cursory knowledge of the patients that the APP sees and little or no time to evaluate those patients independently. If defined patients and scenarios are deemed safe for the patient to be seen by the APP with the supervising physician providing only guidance and backup, then a bill should not be sent in the physician’s name. We support meaningful patient care by the physicians who are billing for it and transparency to patients. A signature in medicine implies that the signatory attests to the accuracy of the document. Without direct evaluation of the patient, how can one know the accuracy of the document?
Emergency medicine residency is a time for physicians to learn how to practice their profession. Residents should be trained by those who practice the profession in which they are seeking board certification. In a situation where APPs are practicing alongside EM residents, it is imperative to establish processes so that the training of the EM residents is not compromised. Residents need to complete a certain number of procedures to become competent. Attaining these skills should be a priority, and the residents should be the first priority to perform a procedure to become independently skilled.
It is challenging, if not impossible, for a patient to determine the role of all the people with whom they interact in the emergency department. Patients can easily be misled by non-physicians using the term doctor. They should not be expected to understand the difference between an MD or DO and a DNP or DScPAS (doctorate of science in PA studies). Patients deserve full transparency about who is caring for them, and non-physician clinicians must truthfully represent their level of training.
Throughout its history, AAEM has consistently asserted that ABEM/AOBEM certification is essential. The academy has also spoken against emergency departments staffed by non-ABEM/AOBEM physicians. Supporting the independent practice of APPs in our emergency departments is inconsistent with these core values. If APP independent practice is tolerated, a logical profit-driven next step is staffing entire emergency departments with APPs and even developing staffing companies to provide that coverage.
Our specialty owes its identity to our founders who demonstrated that the skills required to manage an emergency department expertly were unique in the house of medicine. They struggled to establish the specialty of emergency medicine and define the training required to become a specialist in emergency medicine. The independent practice of APPs has the potential to undermine all the efforts of those men and women who created the specialty of emergency medicine.
©2019 Wolters Kluwer Health, Inc. This article first appeared in Emergency Medicine News, and is reprinted with permission. www.em-news.com.
Highlights for Scientific Assembly 2019
Don’t Miss the Keynote Speaker
We could not be more excited for Scientific Assembly 2019 in Las Vegas. Don’t gamble on missing any of the opportunities to meet with your colleagues
from across the country and hear some of the latest scientific material from your favorite speakers and some exciting new talent. Our ,keynote speaker this year, Matthew Wetschler, MD will share his perspective on life and career. Matthew is an emergency physician, artist, and former professional athlete who drowned and suffered ten minutes of cardiac arrest. Even though he has sustained right-sided weakness, he has developed his artistic talents, and works to explore our relationship with limits, edges, and the space beyond. We are looking forward to his message.
Come Early: Pre-Conference Opportunities
Our pre-conference sessions will include the ever-popular ultrasound, resuscitation, ECG, and LLSA reviews, as well as Medication Assisted Treatment (MAT) waiver training and a session on military hemorrhage control. New this year will be a Written Board Review Boot Camp, for those of you taking the ABEM exam in April, and AAEM will jointly provide a teaching program with the Teaching CoOp, for those of you looking to brush up your teaching and presentation skills.
Back by Popular Demand
This year — back by popular demand — we will double the number of highly popular hands-on small group sessions. Our plenary speakers will cover the latest knowledge on cardiology, sepsis, trauma, resuscitation, critical care, and neurology. Also by popular demand, we will have the Airway Storytelling session, hosted by the unstoppable Billy Mallon. There will be many other events to participate in, such as Open Mic, Resident and Student Research Competition, WestJEM Competition and the RSA sessions. The Wellness Committee has some fun plans, including a new attendee welcome and a coffee crawl for you early risers.
New Panel: Patient as Educator
On Tuesday, the AAEM Scientific Assembly Subcommittee is delighted to announce a pilot format featuring patients as the educators in a session entitled: “Oncology Patient Perspective Panel.” In some diseases, there is no better way to learn about “best practice” than to hear from the patients themselves and see the emergency department (ED) encounter through their eyes. In this session, Dr. Jack Perkins (FAAEM) will serve as the moderator, and the panel will consist of oncologist Dr. Jennifer Vaughn, her patient Mr. Ben Bane, and the wife of her late patient Mr. Jason Price. Both Mr. Bane and Mr. Price spent dozens of hours in the ED with neutropenic fever, various chemotherapy complications, and other oncology related issues. Mr. Bane and Mrs. Susan Price will discuss details of their ED encounters in terms of what went smoothly, as well as opportunities for improvement. Dr. Vaughn will provide insight and expertise in a discussion of optimal collaboration between the emergency medicine provider and the patient’s oncologist.
This session will introduce a new “patient as the educator” format for educational sessions that may be utilized for future scientific assemblies. We will cover best practice in evaluation of neutropenic fever, optimal ways to initiate goals of care or end of life discussions, and the critical importance of collaboration with the patient’s oncologist regardless of the perceived severity of the presenting complaint. Please come to hear this engaging panel where the patients will give us their perspective. We guarantee it will be insightful and valuable.
Because we will be in Las Vegas, you will also have easy access to flights, and the opportunity to take in a show or maybe even practice your card shark skills. Don’t play the odds — join us for some of the best emergency medicine education and a great time!
Tattered Tarp or New Roof: Who Gets Included in Disaster Recovery?
In the bend of the south Texas coast, a community comes together to reflect on a year gone by since many lost everything. We danced in the streets, honored one another’s hardships and congratulated each other’s resilience, and I reflect on my own experience.
The last move my husband and I made before evacuating with our toddler and seven month- old was to throw an anchor from our sailboat, sitting on its trailer, in the front yard, a hundred feet from the water’s edge. “Maybe that will keep her from surfing into the neighbor’s second story living room,” my husband half-heartedly joked as he climbed into our small RV, wet from the first bands of the storm blowing ashore. At 5:30am, we left our home, driving in 20-minute shifts, exhausted from a day and a night of increasingly frantic preparation. Less than 12 hours later, the eye-wall of Hurricane Harvey made landfall directly on our small hometown of Rockport, Texas.
We returned to “The Charm of the Texas Coast” two days after the storm. Half of the structures were damaged beyond repair, the electrical grid was a tangle of wires and snapped poles, there was no running water, and overnight there was a new homeless population. The nearest hospital was destroyed and the majority of doctors’ offices closed due to damage. Rockport (Aransas County), Texas, was already designated a Medically Underserved Area. Like so many coastal communities, it is a glaring example of wealth inequality and social stratification; vacation homes and trailer homes. The storm’s destruction exacerbated an already failing safety net of health care and left our vulnerable population struggling with added mental and physical stress, financial devastation, and decreased access to primary care resources. It was obvious that the community needed a local medical response. After a short and self-guided course on legal protections for volunteer medical professionals in disaster zones, approval from the city Emergency Manager, and crucial support, both on the ground and remote, from a small group of graduates of the Latin American School of Medicine, I founded the Rockport Strong Mobile Medical Unit (RSMMU). For four months, RSMMU served as a pop-up urgent care clinic, staffed with volunteer physicians, nurses, and community health workers, operating out of the same RV in which my family had evacuated. Working alongside Emergency Management and FEMA, we provided free medical attention to over 400 patients.
Our team conducted a survey analysis to determine some characteristics of the population seeking our services. Some of the more important questions we asked our patients were if they had a primary care provider (61.5% reported they did not) and if they had health insurance (68% said no). And to the question, “Do you use the ED as your primary care provider?” 34% said they did. Of note, 74% of patients reported negative effects of the storm on their physical and/or mental health. The stories of the people represented in these figures were just as disconcerting: “I lost everything. I didn’t qualify for assistance. I don’t have a spare dollar to my name. My house is molding. I can’t afford my prescriptions.”
A year later, tattered blue tarps fail to cover the holes in roofs spaced throughout the community. Whose roof, though? Well, this is a diversity and inclusion column, so I bet you can guess. First, let’s talk about disaster vulnerability and how social conditions and location lend to the potential for greater harm to some social groups during a disaster and in the immediate aftermath. Social class factors force the poor to live in substandard housing, often located in physically vulnerable areas such as flood zones and in proximity to industrial sites, and reduce the ability to undertake loss-reduction measures (boarding windows, stockpiling supplies). In the U.S., race and ethnicity are strongly correlated with social class and are also associated with increased vulnerability to disaster.1
In the intermediate phase of disaster recovery, the same differential presents itself. Research conducted in the months following Hurricane Harvey found that the population affected differs by geography, race/ethnicity, and income, the largest impact felt by Blacks, Hispanics, and those with a self-reported income <100% FPL.2 Loss of income and employment disruption had a larger effect on Hispanic, Black, and lower-income residents. Among those with home damage, low-income, Black and Hispanic residents were less likely to have had insurance. Blacks and low-income residents also reported in higher percentages that they were not getting the help they needed. Language barriers arose as a contributing factor to sluggish recovery. Three in ten individuals answering a survey in Spanish reported that it was very or somewhat difficult to find information in Spanish regarding recovery assistance. The study also conveyed that undocumented migrants are particularly vulnerable to the effects of natural disasters, in part out of fear of exposing themselves or family member’s immigration status, and in another part due to ineligibility for benefits.
Now let’s look at long-term recovery and what has recently come to light. A study published in August (2018) concludes that wealth inequality increases along the lines of race, education, and home ownership in counties badly hit by natural disasters.3 In areas with at least $10 billion in damages, Black, Hispanic, and Asian communities saw their wealth decrease by an amount between $10,000 and $29,000, while white communities increased their wealth by an average of $126,000. The study suggests that the money follows the higher levels of reinvestment via infrastructure improvements and low-interest loans after a disaster occurs, as more privileged residents gain access to new resources. Meanwhile, low-income and non-property owners are more likely to experience financial strain from losing one’s job, moving, paying higher rents due to housing shortages, and depleting savings trying to compensate. Contrary to an often repeated myth, this data does not support the idea of disasters being “great equalizers.” It does however bring attention to the fact that for some people the resources which flow into disaster zones can be a silver lining to a universally bad situation. I witnessed this in Rockport as it became a temporary boomtown for construction contractors, clean-up crews, and donation sites across town. The issue is that the silver doesn’t seem to be making it into all folk’s pockets, especially for people of color.
What can we do? Disasters are great disruptors, and where there is disruption, there is room for innovation. After Hurricane Mitch slammed Honduras in 1998, Cuba responded by founding an international medical school, The Latin American School of Medicine (Escuela Latinoamericana de Medicina), designed to train doctors from lesser developed countries, mostly people of color, who would return to their medically underserved area when they graduate so that these communities would be healthier and more prepared for disasters in the future. This plan obviously took a very long view of disaster response, as the first graduates would have returned home some seven years after Mitch made landfall. It’s an example of a long-term disaster response that promotes inclusion and diversity in terms of both the medical profession and access to health care. The free mobile clinic in Rockport was a much= smaller and shorter-term response, but was still a successful innovation that brought resources to a medically underserved disaster zone. It is a model that can easily be recreated when the need presents.
The scientific community warns us that our warming planet will make high-magnitude weather events like hurricanes Katrina, Harvey, and Maria more frequent over the coming years. What does this mean for the health of communities of color exposed to these forces of destruction? Unfortunately, if disaster recovery maintains the pattern of reinforcing gaps in wealth along racial lines and the strong correlation between socio-economic status and individual health is also maintained, it’s likely that the health of communities of color will disproportionately suffer. While the issues are systemic, there are roles that individual physicians can take to immediately address some of the social determinants of health at play in post-disaster communities. Here are three suggestions:
- Set up a free clinic or volunteer to staff if one is already operating.
- Consider in-kind donations of medical equipment.
- Get involved with Emergency Management and advocate for the funding of programs that will improve access to health care (a community health center, for example).
Innovate. We need to change the trajectory of who gets to recovery from a disaster. The resilience and diversity of our communities depend on it.
1. Tierney, Kathleen. (2006). Social inequality, hazards, and disasters. On Risk and Disaster: Lessons from Hurricane Katrina. 109-128.
2. Hamel, L. et al. (2017). An Early Assessment of Hurricane Harvey’s Impact on Vulnerable Texans in the Gulf Coast Region: Their Voices and Priorities to Inform Rebuilding Efforts. Kaiser Family Foundation and Episcopal Health Foundation. http://www.episcopalhealth.org/files/7315/1240/4311/An_Early_Assessment_of_Hurricane_Harveys_Impact.pdf
3. Junia Howell, James R Elliott. (2018). Damages Done: The Longitudinal Impacts of Natural Hazards on Wealth Inequality in the United States, Social Problems, spy016, https://doi.org/10.1093/socpro/spy016
Highlights of AAEM's Legal Advocacy for Emergency Physicians
In the 25 years since AAEM’s founding, the Academy has been very active in advocacy and legal efforts on behalf of individual emergency physicians and independent groups. AAEM continues to be the only emergency medicine (EM) professional society ever to take legal action against contract management groups (CMGs) in defense of emergency physicians. The Academy’s willingness to put the interests of individual emergency physicians over corporate interests has had a major impact on our specialty.
Corporate Practice of Medicine
Catholic Healthcare West (CHW) and Emergency Physician Medical Group (EPMG)
In 1997, CHW, one of the largest hospital chains in the country, announced the purchase of EPMG, a privately held emergency medicine (EM) group. For the first time, a large hospital system had taken over a large EM group, converting hundreds of private practice emergency physicians into hospital employees. The $36 million purchase price was to be recouped by CHW from revenue taken from the professional fees of those emergency physicians. EPMG’s principal owners earned millions of dollars on the sale, and were then given jobs in the new CHW managed services organization, Meriten, which was essentially a contract management group. All current EPMG physicians — staffing eight of the 37 CHW hospitals — immediately became part of Meriten. Even more concerning, the independent emergency physician groups staffing the 29 CHW hospitals that were not part of EPMG were to be forced under the control of Meriten, which planned to take a 28% fee from its emergency physicians’ fees for expenses and profit.
With 29 contracts at risk, the regional implications were profound. AAEM also recognized national implications, as every large hospital system would see the opportunity to control and profit from their emergency physicians. After AAEM wrote letters of concern to the board of CHW, CHW in turn threatened AAEM. Undeterred and with AAEM’s help, the practicing emergency physicians of CHW organized into the Affiliated Catholic Healthcare Physicians (ACHP). With the support of AAEM, ACHP — along with the California Chapter of AAEM and the California Medical Association (CMA) — filed a lawsuit alleging violations of corporate practice of medicine (CPOM) and fee-splitting laws. The CMA recognized both the threat to emergency physician autonomy and the wider threat, as Meriten would also be positioned to control other hospital-based specialists. ACEP was asked to participate in these actions but declined, saying it was a private business matter.
The amicus curiae (friend of the court) brief filed by AAEM in this case can be found here.
After initial court hearings seemed to go against it, CHW sold EPMG back to its original owners, who then reorganized EPMG into a fairer, independent, physician-owned group. If CHW had been successful in this endeavor it would have opened the door to other hospital chains taking over emergency physician groups large and small, dipping into emergency physicians’ professional fees as a new source of revenue, and dramatically reducing the number of private EM groups. AAEM, at the time a fledgling organization, was the only EM society willing to stand with the ACHP physicians. This stand changed the course of EM in California. In the aftermath of this failed attempted takeover of EM, the chief medical officer (CMO) and chief executive officer (CEO) of CHW both resigned.
Mount Diablo Hospital (MDH), California Emergency Physicians (CEP), and TeamHealth
In 2003, Quantum Health, a subsidiary of TeamHealth, the second largest EM contract management group (CMG) in the United States, lost its contract at Mount Diablo Hospital in Concord, California to CEP. Three of the emergency physicians there wanted to continue working at MDH, where they had each been on staff for years. One was even a former Medical Staff President. In response, Quantum Health filed suit against these doctors, seeking damages from them for their supposed role in the loss of the contract. The emergency physicians went to ACEP for help and were told, as in the CHW matter, that it was a private business matter. They then came to AAEM and were provided advice, support, and legal assistance. The doctors joined AAEM in a counter-suit against TeamHealth, alleging that TeamHealth was using corporate subsidiaries to hide its violation of California’s prohibition on the corporate practice of medicine (CPOM). AAEM sought a declaratory judgment, requesting that all ED staffing contracts held by TeamHealth subsidiaries in California be voided, in light of California’s CPOM laws. This counter-suit was the first legal action ever taken against a CMG by an EM professional society.
All parties reached a settlement whereby TeamHealth dropped its lawsuits against the emergency physicians, who were able to continue working at MDH, and AAEM dropped its lawsuit against TeamHealth for violating California CPOM laws. In 2005, AAEM assisted in similar cases in Rhode Island and Indiana, also with favorable outcomes.
A copy of the AAEM counter-suit can be found here.
Read the full story from Emergency Medicine News here.
CMGs and Malpractice Coverage
In 2003, PhyAmerica, one of the largest CMGs, went bankrupt. In 2004, Sterling Healthcare, another large contract management group, purchased PhyAmerica’s bankrupt assets, including its ED contracts. PhyAmerica then told its emergency physicians that their self-insured medical malpractice/legal defense fund had been exhausted. 200 PhyAmerica emergency physicians who had already been sued were told they no longer had malpractice coverage, and must pay all attorney fees and legal judgments out of their own pockets. And of course, PhyAmerica emergency physicians had no malpractice coverage for future suits. In response, AAEM organized a Working Group from among the affected emergency physicians, handled logistics, and offered free legal counsel. The Academy also filed an amicus curiae brief before the Baltimore Bankruptcy Court.
In April of 2005 a court order guaranteeing the protection of the physicians’ personal assets was handed down. AAEM also negotiated with Sterling Healthcare for partial reimbursement of the emergency physicians’ legal costs.
Corporate Practice of Medicine
Emergency Physicians Professional Association (EPPA) and EmCare
In 2004, EmCare, the largest emergency medicine CMG, acquired the contract at Methodist Hospital in St. Louis Park, Minnesota. EPPA, a private democratic group serving the hospital since 1969, was not even told the contract was up for bid until after the contract was awarded to EmCare. No request for proposals was issued. EPPA’s physicians initially reached out to ACEP for support through its state chapter, but were told this was not allowed by national ACEP. EPPA then asked AAEM for help. AAEM Past President, Dr. Robert McNamara flew to Minnesota and met with nearly 100 emergency physicians. The Academy offered legal counsel, went to the hospital on EPPA’s behalf, and filed complaints with the state attorney general and Board of Medicine. In December of 2004, AAEM and EPPA jointly filed suit against EmCare for violating CPOM and fee-splitting laws, and filed suit against the hospital for breach of contract. A copy of the suit can be found here.
Three weeks later, Methodist Hospital terminated its relationship with EmCare and re-contracted with EPPA. EPPA continues to serve Methodist Hospital and several other local hospitals. AAEM then sent a letter to every hospital administrator in the state of Minnesota, informing them of this matter and sending the message that AAEM is watching what they do with their EDs. This action had a chilling effect on the desire of layperson-owned CMGs to move into Minnesota, and they have been unable to establish a significant foothold in that state.
Read more from EM News.
The Fight Against Alternate Boards
The American Board of Physician Specialties (ABPS) began approaching state medical boards seeking formal recognition beginning in the early 2000’s. State boards do not generally control what specialties different physicians may practice, but several state boards limit how physicians may describe their specialization, typically in the form of advertising. The ABPS describes itself as “… the official multi-specialty board certifying body of the American Association of Physician Specialists (AAPS).” It offers certification in 20 different specialties, but review of its website reveals that the majority of its diplomats are certified in a single specialty: Emergency Medicine. Their designation is “Board of Certification in Emergency Medicine” (BCEM).
AAEM believes that “A specialist in emergency medicine is a physician who has achieved, through personal dedication and sacrifice, certification by either the American Board of Emergency Medicine (ABEM) or the American Osteopathic Board of Emergency Medicine (AOBEM).” The fundamental problem with the BCEM process is that it does not require formal ACGME accredited Emergency Medicine training. Rather, an applicant can qualify after completing one of a large number of alternative specialty training programs or even one of 14 EM fellowships, harkening back to the ABEM and AOBEM “Practice Track ” provisions that closed in the late 1980’s. State board recognition of BCEM allows these physicians to misleadingly represent themselves as EM specialists.
In 2002, AAPS certified physicians were approved by the Florida Board of Medicine for such advertising. In 2010, similar recognition was granted in Texas. However, AAEM has been a staunch opponent of back-door paths to proclaim “board certification” outside the ABEM/AOBEM process.
AAEM played a key role in successful efforts in Oklahoma, North Carolina, Utah opposing AAPS’s attempts to gain similar status in these states. AAEM member Dr. Howard Roemer, was awarded AAEM’s James Keaney Award for his key role in convincing the Oklahoma State Legislature to reject AAPS’s proposal. AAEM remains the only EM organization requiring board certification to be a full voting member and a fellow of AAEM.
Read the February 6, 2006 letter to OK Board of Osteopathic Examiners.
Read the AAEM Values Statement, describing EM Specialist.
Restrictive Covenants in Tennessee
In 2005, legislation was introduced to allow restrictive covenants in physician employment contracts in Tennessee. AAEM and its Tennessee chapter strongly opposed these efforts and made this issue a top legislative priority for the next two years. TN-AAEM Board members Dr. David Lawhorn and Dr. Andy Walker testified before the House committee reviewing the bill, and explained to committee members how such non-compete clauses harm both patients in general and emergency physicians in particular.
While TNAAEM was not able to kill the bill entirely, emergency medicine was exempted. Emergency physicians in Tennessee remain free of restrictive covenants to this day.
Read more at EM News.
Corporate Practice of Medicine
TeamHealth and the Memorial Hermann Hospital System (MHHS)
In 2007, MHHS, a large hospital network in Houston, awarded eight emergency department contracts to TeamHealth. Several emergency physicians contacted AAEM for assistance in this matter, including a private group with a 20-year history with MHHS, which was ousted in this move. AAEM and the private group — with AAEM’s financial assistance — filed suit against TeamHealth and MHHS, citing violation of Texas CPOM laws. AAEM felt the case had substantial footing, as the Texas Medical Practice Act prohibits physicians from being employed by lay corporations for the practice of medicine. Additionally, previous Texas case law (Flynn Brothers, Inc. v. First Medical Associates, Dallas 1986) held that lay persons could not profit from an ED contract. AAEM’s efforts were funded through donations to the AAEM Foundation.
Unfortunately, a state district court held that it did not have jurisdiction to hear the case. Despite an amicus curiae brief filed in support of AAEM by the Texas Medical Association, a state appeals court affirmed the district court’s decision. The court of appeals held that AAEM lacked standing to challenge the contract between MHHS and TeamHealth, as well as the contracts between TeamHealth and its emergency physicians. One of the plaintiff physicians actually signed a contract with the TeamHealth subsidiary, but even then the court would not grant a declaratory judgment enforcing the state CPOM laws, holding that private individuals could not enforce the Texas Medical Practice Act. The court did leave open the possibility that physicians could file suit to nullify their contracts with a lay-owned corporation, as such contracts may violate state CPOM laws.
AAEM then appealed to the Texas Supreme Court, which refused to hear the appeal. As a result, neither the Academy nor the plaintiff physicians ever got the chance to argue the merits of their case before a judge or jury, and no judgment on the merits of AAEM’s corporate practice of medicine claim was rendered. AAEM still believes it could win in court on the issue of the corporate practice of emergency medicine in Texas.
Read more from EM News.
Due Process / Whisteblower Case
Dr. Genova versus Banner Health
In January of 2010, emergency physician Dr. Ronald Genova contacted the hospital administrator on-call, the hospital CEO, requesting to implement a “Code Purple” to divert patients to other hospitals, because he believed the ED at North Colorado Medical Center could no longer provide appropriate and timely screening to patients due to excessive crowding. According to the facts alleged in Dr. Genova’s lawsuit, a patient with a GI bleed had already collapsed in the waiting room bathroom while awaiting evaluation and two heart attack patients had just presented to the ED. According to Dr. Genova, the hospital CEO refused the request. Two weeks later, in apparent retaliation, Dr. Genova was removed from ED duties.
Dr. Genova filed a lawsuit noting that his removal from the schedule violated EMTALA whistle-blower protections and the covenant of good faith and fair dealing implied in contracts by Colorado law. The federal District Court dismissed Dr. Genova’s suit, citing that Dr. Genova signed away his right to sue the hospital when his group contracted to provide physician coverage of the ED. Dr. Genova then asked for AAEM’s assistance. In November of 2012, Dr. Genova appealed, and AAEM filed an amicus curiae brief asking the appellate court to overturn the dismissal and have the allegations in the complaint adjudicated on its merits. AAEM argued that the District Court imposed too narrow a reading of EMTALA’s whistle-blower protections. AAEM also argued that a hospital should not be allowed to insist on a waiver of the covenant of good faith and fair dealing, as that implied covenant serves not only to protect the physician but also patients. While the 10th Circuit Court of Appeals favorably discussed the arguments made by AAEM, it ultimately upheld the dismissal. Although AAEM is disappointed with the outcome, this case demonstrates the Academy’s willingness to come to a member’s aid when their practice rights are threatened.
The AAEM amicus curiae brief can be accessed here.
Cross Subsidization, Fee Splitting, CPOM
In 2014, Tenet Health, one of the largest hospital networks in the country, put the contracts out for bid at 11 of its hospitals in California, to replace their emergency medicine, anesthesiology, and hospitalist groups. Many of these groups had served their hospitals and their communities well for decades. Such a change would be highly disruptive to the hundreds of physicians who have learned the systems and processes of their practice over time, and have developed relationships with their hospitals and medical staffs — not to mention the disruption to local nursing staffs, patients, and communities. Most of the hospitalist contracts and some of the anesthesiology contracts included a subsidy from Tenet, while most of the EM contracts generated enough revenue through collected professional fees to be entirely self-supporting and quite profitable.
Tenet solicited several large CMGs seeking a no-subsidy arrangement for all contracts. Essentially, Tenet wanted the profits from the emergency medicine contracts to cover its losses on the hospitalist and anesthesiology contracts. In addition, the emergency medicine practices will serve as a piggy bank to be raided by the CMG and the hospital. Of course, the CMG needs to show a nice profit to its investors too, which is hard to do without the anesthesiology and hospitalist subsidies. So, this also raised concern for future belt-tightening at the affected hospitals: less physician coverage, greater use of NPs and PAs, and lower pay for physicians. Federal fee-splitting laws, enacted to prevent kickbacks and abuse, prohibit the distribution of part of a physician’s professional fee to any entity, in excess of the fair market value of services provided to that physician. When part of a physician’s professional fee is being distributed to a hospital or CMG, the parties involved may be in violation of those laws. If an emergency physician’s professional fees were to go towards subsidizing other hospital-based specialists, or to pad the bottom line of a for-profit corporation, this would appear to be an extreme violation of federal fee-splitting laws. It is also important to recognize that California has some of the strongest corporate practice of medicine (CPOM) laws in the country. These laws, drafted to protect the public due to the potential for abuse when a corporation’s fiduciary duty to its shareholders is in conflict with a physician’s duty to his or her patients, prohibit non-physician, lay corporations from owning or controlling physician practices.
The leaders of several groups affected contacted AAEM and asked for our assistance. AAEM and its California chapter provided advice to the affected groups, sent letters outlining AAEM’s concerns to the relevant hospital leaders, hospital boards, and medical staffs; and engaged in discussions with Tenet Health leadership. AAEM and the affected groups organized a highly effective public relations campaign. AAEM President Dr. Mark Reiter was quoted in many media outlets, noting his concerns that Tenet Health’s proposal was bad for Tenet’s hospitals, bad for its physicians, and bad for its patients. Soon after, Tenet’s leadership informed AAEM that they were no longer considering this course of action, and that the local groups would remain.
Read the September/October 2014 President’s Message: Tenet Wants Emergency Physicians to Subsidize the Rest of the Hospital.
Read the November/December 2014 President’s Message: Tenet Health Update & Opportunities with AAEM.
Fee Splitting, Anti-Kickback, CPOM
Over the past decade, the largest hospital network in the country, Hospital Corporation of America (HCA), entered into a joint venture with EmCare/Envision, the largest CMG in the country. Under this arrangement, via the joint venture, the hospital and the CMG jointly own the emergency physician group and split the profits resultant from the emergency physician professional fees. Although CMGs have profited handsomely from emergency physician professional fees for decades, this was new territory for hospitals. In the past few years, HCA has brought most of its EDs under the joint venture, destroying dozens of independent EM groups. In return for being able to keep working in the same ED, many of these physicians are forced to take significant pay cuts and lose much of their independence and job security. Several other hospitals and CMGs have engaged in similar arrangements on a smaller scale.
Since hospitals and CMGs are typically not physician-owned corporations, having a hospital-CMG joint venture owning or controlling a physician practice may violate corporate practice of medicine laws in many states. In addition, federal fee-splitting laws, drafted to prevent kickbacks and abuse, prohibit any portion of the physician professional fee from being distributed to any entity in excess of the fair market value of any services provided. In addition, there is concern that these arrangements violate federal anti-kickback laws.
AAEM, in conjunction with a prominent law firm, has been actively investigating potentially illegal activities and hopes to enforce any prohibitions on such activity. AAEM has brought its concerns to a variety of federal and state agencies, many of which have voiced significant concerns with the legality of these arrangements and continue to investigate. AAEM has also passed a position statement noting its opposition to these joint venture arrangements and has discussed the issue with the media.
Unfortunately, we have not been successful in shutting these joint ventures down, but we will continue to be the only professional organization that is fighting for its members on this important issue.
Read the May/June 2014 President’s Message: Hospital-Contract Management Group Join Ventures: A Disturbing Trend.
AAEM Physician Group
For years, AAEM has been the strongest advocate in the house of medicine for physicians owning and controlling their own practices. Practices owned by a small subset of their physicians or entirely owned by lay corporations are much more likely to lack transparency, political equity, and financial equity. This can create conditions ripe for exploitation. AAEM has worked hard to promote equitable, democratic, physician-owned practices throughout its existence. Despite AAEM’s efforts, physician-owned practices are under significant threat. Small practices may have difficulty developing and maintaining the infrastructure needed to be successful in the new reality of health care reform, accountable care organizations, and value-based purchasing.
In 2016, the AAEM Physician Group was launched to combine the advantages of small, democratic groups of physician owners, with the economies of scale, expanded services, and clout of large groups. Likewise, the AAEM Physician Group can help minimize the time, resources, and risk to emergency physicians who want to create their own EM group, or to bring the control of their group back to the physicians actually practicing in their ED. AAEM has created a new paradigm whereby smaller EM groups could become part of a national collaborative with access to best-in-class practice management services provided at fair market value. For existing groups, we believe the addition of more professional management will help them maintain their contracts and facilitate possible expansion. Moreover, as part of AAEM, we believe affiliated groups will garner significant legal protection under the existing prohibitions on corporate practice of medicine and fee-splitting. Unlike the Memorial Hermann case mentioned above, AAEM will now have “standing” in any threat to the contract. Likewise, AAEM Physician Group can seek new, high quality ED contracts and then set up and install local, democratic groups at these sites. We developed a set of fairness principles that would be required for participating groups to meet (i.e., financial transparency, reasonable path to partnership, due process, political and financial equity) to ensure that the commitment to a fair environment would be maintained.
The AAEM Physician Group is off to an excellent start. We now have multiple EDs representing hundreds of thousands of patient visits partnering with us as part of the AAEM Physician Group. Each group maintains local ownership and control while being obligated to follow AAEM’s Fairness Principles. If your group is interested in learning more about the AAEM Physician Group, please contact its CMO, Dr. Robert McNamara at email@example.com
Read the September/October 2015 President’s Message: The AAEM Physician Group at: http://www.aaem.org/UserFiles/file/CS_SepOct2015_ President.pdf
As you can see, the Academy has been extremely active in protecting the practice rights and livelihoods of emergency physicians, who often have nowhere else to turn for support in such matters. Many of our advocacy and legal actions have been successful and substantial, with significant benefits to the emergency physicians involved — including saving their jobs. There is still much to do, however, especially in an environment where lay-owned, corporate, contract management groups — which often have a very poor track record regarding restrictive covenants, due process, and other practice rights — control a large proportion of emergency medicine jobs. Your AAEM membership, your active support of its work, your recruitment of new Academy members, and your donations to the AAEM Foundation provide the resources the Academy needs to be a successful advocate for the practicing emergency physician.
The links below are further readings on this matter:
Emergency Medicine at Risk?
You may have heard it said that we really don’t have a health care system, rather a health care mess. I disagree. Our system is actually quite good at doing what it is designed to do. Let me explain by starting with some definitions.
Health care is the prevention, treatment, and management of illness or injury by health professionals.
Physicians deliver health care along with the advance practice providers, nurses, techs, respiratory therapists, physical therapists, etc. that we guide. Hospitals, insurance companies, pharmaceutical companies, pharmacies don’t deliver health care. They may be part of a system within which health care is delivered but they don’t deliver health care. What should their role be? Let’s look at another definition.
According to the Business Dictionary a system is an organized, purposeful structure that consists of interrelated and interdependent elements (components, entities, factors, members, parts etc.). These elements continually influence one another (directly or indirectly) to maintain their activity and the existence of the system, in order to achieve the goal of the system.
If you think of the various entities in our “system” — pharmaceutical companies, hospitals, insurance companies, medical device manufacturers, contract management groups, pharmacies, and a host of others — they are certainly interrelated and continually influence on another to maintain their activity. They just have the wrong goal. Their goal is to make money and as evidence by the fact that we spend around 18% of our GDP on the delivery of health care they are very good at it. The goal should be to support the delivery of health care. Everything these entities do should foster and facilitate the physician-patient relationship. We all know from our various experiences that our system does not support but rather uses and in some cases corrupts the physician-patient relationship. That corruption is the root cause of much of the burnout we observe in our practices, in my opinion. But I digress.
Change is going to happen because the economists and other “experts” believe that the spending is not sustainable. They are probably right but it is a by-product of our system so efforts to control the spending must necessarily change the system. This will be a monumental task simply because there is so much money involved and no one will voluntarily give that up. Those with the best lobbyist have their turf protected. Physicians are very bad about organizing and devoting their time and money to protect their turf, believing the sanctity of the patient physician relationship will protect them. I may be cynical but I think that belief is naive.
I think this poses a very real threat to emergency medicine. It is widely believed that the care delivered in the emergency department is too costly. Efforts to show that it is only a small part of the overall health care spend are important but I believe will not be enough to protect our turf. Strides to defend the prudent layperson standard and prevent post treatment denials of payments such as Anthem has announced, are crucial. I am not sure they will be enough. I believe that someone will figure out how to keep the patients that “don’t need to be there” out of the emergency department. I am not talking about the patients that we can all agree that don’t need to be there — they probably don’t even need a doctor. I think the big challenge is those patients that we see every day that don’t need to be there but we don’t know this until after we see them. Pay attention during your next shift. How many patients can you determine after one or two minutes don’t need to be there? I know that the professional fees are not the problem. The facility fees are typically 5-10 times the professional fees. The hospitals are not going to bring those in line. Anthem and United recognize this and that is why they are retrospectively denying payments.
With challenges comes opportunity. Emergency medicine is a unique specialty we are defined by a patient population (those that present to an emergency department) and not, like most other specialties, defined by an organ system or disease process. We still may be defined by a patient population but within the house of medicine our role has evolved. We are now the specialty that treats almost all patients with undifferentiated acute illness. We are the specialty that puts the puzzle together and makes the diagnosis. Our skill set is crucial. Is it necessarily tied to hospital based emergency departments? Sure, we need some tools to do our job but the decreasing cost of tools no longer necessitates them being in hospitals. The growth of freestanding emergency centers (FSEC) in many areas of the country was fueled by this recognition and may be part of the solution. However, the “cost” of the FSECs are not much less than the hospitals. Urgent care centers largely lack the expertise and equipment to make a big impact.
Emergency medicine needs to understand that change is coming and that it is a particular threat to our specialty. But also recognize that our expertise is crucial and put forth “out of the box” solutions before the “system” defines our role going forward. Our “system” is very good at what it does — make money. If we don’t define the solutions we run the risk of being left out of the money.