The Rape of Emergency Medicine
Issue: November/December 2020
Author: Andy Mayer, MD FAAEM
Editor-in-Chief, Common Sense
I would like to propose a challenge to each of you and it is to read a book. Have you ever read Jim Keaney’s “The Rape of Emergency Medicine?” If so, how long ago? Maybe now is the time to read it for the first time or to reread what to many was the call to arms for action when the Academy was founded. It was initially released in 1992 anonymously by “The Phoenix.” At the time, there was a significant danger of losing your job for speaking out for many of the issues which led to the founding of the American Academy of Emergency Medicine (AAEM). Many of you might consider it ancient history but the themes are relevant today. The book is available for free on the AAEM website to read online or download. It is a quick read and will not take much time.
Read “The Rape of Emergency Medicine” here: https://www.aaem.org/about-us/our-values/history.
The characters and business practices portrayed in the book may seem humorous and on a superficial analysis only relate to controversies of the past. The book decries the rise of the corporate practice of emergency medicine and the attempt to destroy the independent practice of our specialty. The rise of the “suits” from kitchen schedulers to the goliath corporate management groups is portrayed by some memorable characters. The exploitation of the “scrubs” by these non-practicing physicians and their relation to the early leadership of organized emergency medicine is a topic which each of you needs to know about, understand, and reflect upon. Please consider that these issues are not things of the past. They are not historical curiosities to be relegated to the dustbin. The suits have in many cases sold out for untold millions of dollars to private equity corporations. These corporations are often publically traded for-profit multibillion dollar corporations as opposed to the kitchen scheduler of old. This makes them more and not less dangerous to our profession. These corporations control the careers of thousands of emergency physicians and it is hard to believe that their motivation is anything but the bottom line and the return on investment to their shareholders.
Improvements have been made by the organizations who are supposed to represent and protect each of us and our specialty. Hard lessons have been learned and some of the situations described in the book have been at least partially corrected. Some battles have been hard fought and won and others have been lost. Sadly, our profession contains a large number of “scrubs” who have become the automatons which some of the characters portrayed in the book. These clinicians do not concern themselves with the “business” of emergency medicine and continue to sign the non-compete clauses humorously described in the book. They surrender their due process rights and continue not knowing what is billed and collected in their name.
Maybe you say that it does not matter and that the suits have won and that there is no point in struggling against the system. Maybe you will doggedly work with blinders on while striving to meet whatever metric is thrown in front of you. Your only ambition may be able to ignore the rest and complete your career by checking off the shifts on each schedule. However, maybe now in the time of COVID you may rekindle the spirit and be spurred into action or at least interest.
The morals and lessons from Keaney’s book sound as true to me today as they did almost thirty years ago when I first read it. At that time, I was working part-time at an EmCare facility and I felt exploited and was outraged. Consider the irony of AAEM’s long fight for the value of board certification in emergency medicine. The Academy fought long and hard and made this the core issue for our organization. The numbers of board certified emergency physicians are growing and more and more of our emergency departments are becoming staffed with all board certified emergency physicians. That sounds great but new obstacles have arisen which also threaten our future. There had always been a presumed logic that there were not enough board certified emergency physicians to staff all of our nations emergency departments. Recently, concerns are being raised that this supposition is not true and that in fact there may soon be an actual oversupply of emergency physicians as the number of residency programs run by CMGs blossom.
The real fight may now be on another front. We now may be losing the fight to midlevels. Corporate management groups are quickly learning that they can replace us with cheaper labor. They sponsor training courses for physician assistants and nurse practitioners to make them specialists in emergency medicine and boldly support independent practice for these same midlevels. COVID is being used as the excuse to permanently change the staffing of emergency departments. How many of you have had your pay cut, hours or shifts reduced, or been terminated with the explanation that the current pandemic requires changes in staffing levels? Certainly, the decrease in volumes related to COVID has caused some of even the most independent and democratic of groups to change their staffing levels and hourly wage. We all do work in a business, and business decisions are often painful. I cannot say that any group can put their head in the sand and not do what it takes to survive. My concern is that many corporate management groups are using the crisis as an excuse to decrease long-term costs by placing a midlevel as the backbone of their department’s staffing. This tendency which had previously started is now accelerating. These CMGs simply reduce or eliminated physician double or triple coverage and keep adding midlevels. In doing so, they can pocket the saved labor costs. These corporations are not motivated by an altruistic desire to protect the public or our profession during a pandemic. Are they simply using this crisis as a means to decrease their hourly costs in the long run in an effort to improve their profit margin? It is hard to believe this is being done to improve patient care or satisfaction.
Some organizations representing the nurse practitioners and physician assistants are also using the pandemic to push forward their effort towards total practice independence in the various state legislatures. Many rationalize that the need for expanded practice rights is due to the labor shortages caused by COVID and relate horror stories of overrun emergency departments and hospitals as a justification for independent practice. How many of you are short labor and need to expand the independent practice capabilities of midlevels to meet the care needs of your department? Most places except in a current hot spot have an excessive or even a glut of labor and certainly do not have a shortage of emergency physicians. COVID is simply being used as a cover to distract legislators from the real situation.
Keaney’s book clearly describes the still continuing practice of termination without cause when a physician complains or causes any sort of trouble for the corporate management group. This practice continues to this day and has been highlighted during this pandemic by emergency physicians who have been terminated when they have complained about the lack of personal protective equipment and other safety concerns related to COVID. These terminations are made a simple and quick process because many of us are required to give up our federally required due process rights to obtain a job. This process of “forfeiting” your rights to obtain a job sounds ridiculous and I bet that many of you reading this did so not even knowing it. Who bothers to read all of that fine print when you sign a contract? You think all of those confusing paragraphs buried in the bowels of your contract are not important? You just skipped to the salary part and signed.
COVID does present us with an opportunity in this regard. The Academy has been a champion of legislation to insure the preservation of due process rights for all emergency physicians. Larry Weiss, a past president of AAEM, has been the long-time champion of this effort. AAEM has been attempting to pass legislation and has also tried to work with CMS in this regard. There has been a petition on AAEM’s webpage in this regard for several years. Have you signed it?
Sign the Due Process Petition: https://www.aaem.org/due-process/petition/index.php
Currently, there is again proposed legislation in Congress to help guaranty the due process rights, which are frequently “voluntarily” relinquished by emergency physicians in order to get a job especially with a corporate management group. COVID is providing an impetus to actually pass legislation in this regard. The bill is called the “ER Hero and Patient Protection Act” which has sponsors from both sides of the aisle. Hopefully with the support of the extended medical community this will become law. Several medical organizations have signed on as supporters of this bill including the American College of Surgeons. Please consider reading more about this and becoming involved in this important effort of passing this legislation which is still needed thirty years after the original publication of “The Rape of Emergency Medicine.” Please follow this issue as it progresses through our legislative process. Please help our profession grow from the “scrubs” of old into what we all know is an exceptional rich and vital medical specialty filled with incredibly trained professionals.