Could Things Be Any Worse?
Issue: March/April 2021
Author: Andy Mayer, MD FAAEM
Editor-in-Chief, Common Sense
I recently had a discussion with a group of emergency physicians from various parts of the country and from all sorts of practice types. I respect the opinions and the wealth of experience of this group and of course was also interested in their COVID-19 experiences both good and bad and how their practices had been impacted by the virus. Each of us has a story to tell about 2020 and most would like to hit replay if that were an option. Sadly, during the wide-ranging discussion I heard comments from two different senior and well respected individuals which really stuck out in my mind. Each of these comments made me pause and reflect on them and to try to make sense of how we as a profession have reached a point where these seasoned physician leaders would make these statements and what it means and more importantly what we as emergency physicians should do about it.
The first statement was, “I am just a tool of corporate medicine.” This comment struck me as I highly respect the individual who made it and it deeply upset me at first that he felt that way. I certainly understand why he had become discouraged and how he had come to his sad conclusion. Each of us have had our ups and downs and can make statements at low points which may not reflect our true beliefs or feelings. I did not take his comment as an admission of defeat, but probably more a reflection of a low point which we all can have when our wellness bucket needs refilling. Facing staffing shortages, sick providers, lack of adequate PPE, insufficient equipment, and no empty hospital beds, the strength can be sapped of even the best of us. However, more and more the practice of emergency medicine is adversely impacted by the strangling grip of the corporate practice of medicine and insurance companies.
COVID-19 has caused many of us to face up to the broad range of challenges, which the modern practice of emergency medicine has produced. Each of us has had our own COVID-19 saga, which is a combination of our work, home, and family experiences. We have all had to deal with the social isolation from our family and friends even if your medical COVID-19 experience has not been bad. Some of us faced the initial wave of COVID-19 while others were sitting in empty emergency departments worried about their jobs and salary. Each of us know excellent emergency physicians who have had their hours or salary cut during the pandemic. The corporate management groups have been able to use COVID-19 as a tool in their profit motive to displace board certified emergency physicians. Some of us have faced specific individual threats and termination when advocating for adequate PPE and other COVID-19 related issues. Many are facing later, sometimes overwhelming, waves of patients without the ability to pull in staff from other areas of the country or to have nurses leaving your hospital to seek the premium travel nursing dollar. How many of you are being replaced by lower cost midlevels now during this crisis with the excuse of lower volumes and the need to cut “costs?”
The other comment made was related to the failure of organized medicine to meet the challenges, which have changed the practice of medicine over the past few decades. A senior leader of our specialty was talking about his work within the American Medical Association (AMA). Many physicians have become disillusioned with the AMA over the years, including myself. He has not given up on medicine’s flagship organization and regularly attends meeting and advocates for issues which impact all emergency physicians. However, what he said was the second comment of the night which really struck me and led to the title of this article. He said, “Could things be any worse, even if the AMA didn’t exist?” Think about that sentiment for a minute from someone who has stayed in the fight and dedicated much of his free time to advocate for you within the AMA. Remember that this huge body is supposed to represent and advocate for all of us against the many threats and changes which each and every physician in America now faces. This physician commented that during meetings which set policy and advocacy goals that he reflected while looking around the room. He questioned if the physicians in the room really represented the interests of American physicians or rather the corporate and business interests of the organizations of which they belonged. Even if this is true I would ask whose fault is this? Did the average physician fail to advocate for themselves?
Most physicians spend little or no time in the political or organized medicine world. Most physicians I know have a fatalistic view of the future of the practice of medicine in America. Asking them to become involved by joining an organization let alone writing their congressperson or actually lobbying receives a blank and distant stare of non-committal. Talk to any lawyer whose lobbying and fund raising efforts dwarf medicine’s efforts and hear their point of view. Lawyers look at physicians in shock and bemusement in regards to our feeble lobbying efforts compared to the plaintiffs’ attorney and other attorney groups. Lawyers are not surprised to what has happened to us as we have stood idly by and let medicine become dominated by corporations, insurance companies, etc.
Nurse practitioners and physician assistant lobbying efforts often dwarf organized medicine’s efforts especially in state legislators where the battle of scope of practice is rapidly being lost. Their efforts, especially during COVID-19, are being sold as a way to improve access to care for your patients by allowing “unencumbered” rights of practice for all types on non-physicians. Just look at one statement which can be quickly found on an internet search from the American Association of Nurse Anesthetists which states “Removing Physician Supervision is the Right Thing for our Patients.” What do you think our anesthesia colleagues think about this when they reflect on the time they took to go to medical school and complete a residency?
Other midlevel groups continue to push the envelope and will use us to train them before our utility is no longer desired when we become the expendable “high cost problem” in the budget. I suggest you look up the Yale New Haven Hospital Emergency Medicine AAP Residency Program. It proudly suggests that it is an “18-month postgraduate training program designed to train PAs and NPs in the skills and knowledge required to evaluate and treat the full spectrum of patients seen in the emergency department.” Will for example Doctors of Nursing Practice who complete this “residency” not be able to state without hesitation that they are residency trained emergency doctors?
My point is not to make you more pessimistic about the future, but to emphasize the need for your personal increased interest and efforts right now if we can hope to have an impact on the future of emergency medicine. I make this recommendation to the full spectrum of our emergency medicine community from medical students, residents, young attendings, to our senior leaders. Thinking that you are young and too busy to be involved is short sighted. In a few years, many of the core value issues related to the corporate practice of medicine, due process, scope of practice, or you name it, may be decided. Younger physicians do not have time to wait, especially with the huge increase in the number of emergency medicine residencies and the surge of midlevels entering the market. Our older emergency medicine colleagues also have an obligation to the young to do what they can instead of thinking that the time for them is drawing to a close and that they are just trying to hold out until retirement. Letting an unseen hand direct our future is just asking for trouble. Even with our most committed efforts, we as a profession will not win all of the battles, but by throwing in the towel without any effort, will be rewarded with predictable results. Will you look back later in your career and regret not making every effort to protect our profession? We do not need to play the role of helpless victims in this fight. Physicians are still respected, especially on a local and state level. There is power in numbers and commitment. COVID-19 may be providing the catalyst we need for the house of emergency medicine to stand up and be heard from your state house to Washington. So, the answer is yes, it could be worse and we need to do what we can to prevent that from happening.