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