Common Sense

The Gap

AAEM completed a membership survey of the active membership in an effort to know what our members are thinking and feeling about emergency medicine and our organization. You may have noticed in the last few issues we have published several of the comments submitted by members. It is always important for an organization to reflect on what is important to the very members which form it. The board of directors sat and discussed as a group your comments. I believe that the core values for which the Academy was founded are the core values which we still hold. I have carefully read the hundreds of responses to the membership survey and found two which I think should be explored and discussed. One appears to be from a seasoned veteran and the other from a younger member each with different but important perspectives to consider. Here they are:

Response One

“I’m a 20 year member of the organization. Through the years, the organization has changed and I feel like it’s lost its true north in some respects. The battles with the CMG’s have been lost. AAEM lobbied and fought and argued and wrote and in the end, look where we’re at … Envision/TeamHealth have massive numbers of EDs and most graduating residents just end up as employees. So now what’s left and what differentiates AAEM from ACEP? At this point, I feel like AAEM is the group that a) would stand up for me if I had an issue as an individual physician with my group or hospital and b) does offer amazing, high quality and inexpensive education. But that’s it … SAEM does academic/research better and ACEP does lobbying at the national level better. I’m increasingly finding it difficult to find the gap that AAEM needs to fill besides being another ACEP for people who don’t like ACEP.”

Response Two

“I struggle with paying both ACEP and AAEM. I am young in my career and while I understand issues ACEP has from an independent practice perspective I do not know that it is “egregious” enough for me to boycott their membership. I therefore am left paying double membership. I think this is redundant. I’m concerned that at some point in the future that I will have to pick one organization and I am not yet sure which I will choose. It would be best if you would just merge and have one voice speaking for the profession. Infiltrate the higher levels of ACEP so they represent our voice, bring the two together. It “should” be most economical and the most value to the membership.”

So, what do you think?

Has the battle for our profession been lost and should we just throw in the towel and call it a day? Should AAEM just go away and admit defeat in a noble but hopeless cause? Are the corporate bosses really already in charge of our specialty and we should just admit we are just costly line items to be displaced by midlevel’s on CMG’s books? Does the endless debate and discord between AAEM and ACEP have value? There are many things to consider when we reflect and debate these issues. There are many things which either AAEM and ACEP do and these do have significant value for the membership of each organization but let us look at the points of the two member comments.

The first comment from the more senior member of AAEM is seeking “the gap” that they think AAEM needs to fill to be relevant. They think that we have lost the battle for the control of emergency medicine and that corporate management groups have won. If you look at the number and the geographic penetration of CMG’s particularly in certain areas then he would seem to be correct. Try and find a job in a democratic group in Florida for example and it is easy to become discouraged and lose hope for the specialty. Try and ask what is being billed and collected in YOUR name in many places and you can end up being quickly replaced. Now the explosion of corporate sponsored residencies is providing an inbred supply of young graduates who have never even heard of a different way and are eager to fill schedules and replace the old hands who just don’t understand that emergency medicine has moved on and we are just “labor.” I can certainly appreciate if this member feels the battle is lost but I think there is still hope.

So first, I disagree that the battle is lost. Remember that corporate management groups can only actually make money off of the sweat of others. What do they provide besides a schedule? They have to make money for investors and they have only a limited number of ways to do this and at what cost to our patients? Cutting schedules and replacing physicians with Advanced Practice Providers (APP’s) can only go so far. There are opportunities to fight back and retake some lost ground. This fight is not easy and I don’t think that it is over, but organized medicine should be there to help. Facing the corporate practice of medicine has not, nor will be easy. AAEM has started the AAEM Physician Group to help individual and groups of emergency physicians start fair and equitable groups. Bob McNamara is the champion of this activity and is passionate about helping groups get started. This interest in the emergency physician I think is the main reason to be a member of AAEM. Do you think that an Envision or TeamHealth Executive serving as an officer or president of ACEP can be totally unbiased and care only for the profession of emergency medicine and the well-being of the individual emergency physician? Who do you think is the “Champion of the Emergency Physician?”

The veteran emergency physician does think that AAEM would “stand up for me if I had an issue as an individual physician with my group or hospital.” This has always been one of AAEM’s key strengths and why we really are the champion of the emergency physician. Individual physicians having a practice issue can call and speak to a board member usually within a day. AAEM has provided expert legal, professional and moral support for a myriad of issues over the years. There are many examples of AAEM showing up and that is enough to stop an action which would have destroyed a long standing group and kept out a CMG simply by publicly shaming the players involved. This is often after being told by ACEP that they cannot become involved in “private business matter.” I have always found it to be ironic that many ACEP presidents and board members certainly do work on these very matters on a regular basis except that is in their role at corporate management groups.

The last point of the first comment relates to AAEM’s medical education opportunities. If you have never been to the Scientific Assembly then you are missing out on a spectacular meeting. Granted there are not a lot of free shrimp lying about and there are no major galas sponsored by CMG’s to enjoy. However, there are fantastic speakers giving relevant talks directed at practicing board certified emergency physicians. There are plenty of social activities to meet and commiserate with “pit docs” who are fighting the same fight as you are every day.

Our second comment comes from a younger emergency physician who is rightly concerned about the cost of paying dues to two separate professional societies and asks if doing so has adequate value to justify the expense. They suggest that the two organization could somehow fuse into a single enlightened organized with the strengths of both. Our younger physician recommends AAEM somehow “infiltrating” the higher levels of ACEP so that our ideals could be represented by ACEP. Certainly, it would be nice if emergency medicine could be represented by one united society where the stakeholders were passionate and sincere in their pursuit of improving all aspects of our specialty. I certainly agree that AAEM does not need to reproduce every aspect of ACEP. ACEP currently has the size and scale of numbers. AAEM is smaller but seems to significantly out shine ACEP in advocating for the best interest of individual emergency physician. AAEM certainly advocates for issues which seem to resonate with our motto as the “Champion of the Emergency Physician.” Could and should ACEP advocate more for the value of board certification, due process, etc. and against the corporate practice of medicine and the expansion of the role of mid-levels? I certainly think the vast majority of the membership of both organizations would support this effort. However, in reality if the upper levels of leadership of ACEP are dominated by executives of corporate management groups do you really think this will happen. Do you think that the CMG’s want to support the individual physician or small democratic groups? Do they want due process or do they want to keep the ability to arbitrarily fire a troublesome doctor who speaks up for their patients or wants to see what is billed or collected in their name?

My conclusion is that I do not for the foreseeable future predict that AAEM and ACEP will fuse into one organization for several reasons. I do see a value in both. Many will have a moral or philosophical reason for not joining one of the organizations. This is certainly my case with ACEP. Yes, it is hard to be members of both organizations and you may choose to only be a member of one. I chose AAEM and others pick both or only ACEP. I respect all of these choices. The emergency physicians I really am concerned with are those who chose neither and throw up their hands or worse are so burned out that they do nothing and await their future as a simple laborer to a corporate manger until replaced by a mid-level.