Common Sense

Boldly Moving Forward: Learning to Be Proactive Rather than Reactive

Issue: July/August 2019

Author: David A. Farcy, MD FAAEM FCCM
President, AAEM


In the past several months, I have been traveling and lecturing to students, residents, and attendings, at both community hospitals and at academic programs. While speaking with people on my travels, I often am asked “Why should I join AAEM?” “What do I get for my money?” “I am content, I am happy where I am!” But in the same sentence, I also hear, “What are you doing about wellness?” “What are you doing to support women in emergency medicine?” etc. As I respond to these questions, filling them in on the great work the Academy is already doing through our Wellness and Women in EM Committees, and many other initiatives, this is usually met with, “Wow, really?! You’re not marketing yourself well, we had no idea.”

Based on this feedback, I surveyed my own program and asked a room of over 30 people if they had read my last president’s message, and I regret to report that only two hands rose. (And, yes, one was mine!)

When people are passionate about something, it drives them to become engaged, to learn, to educate, and to want everyone else to listen too. However, most often the reality is that we are “too busy,” or have “no time” to take up just another concern in our already busy personal and professional lives. I am deeply passionate about the work AAEM is taking on and my wish is for all of our members to be passionate as well.

We as doctors, are too often reactive instead of being proactive. We’re too often afraid that we might cause waves by taking a stand or we might be viewed as having too politically charged of a stance on issues. But when the NRA attacked physicians with their “stay in your lane” tweet last November, we all came together, social media blew-up, and AFFIRM research was created (American Foundation for Firearm Injury Reduction in Medicine). I am sure we have card-carrying NRA members amongst our membership and we might have upset some of them or even worse had some resign from our Academy. But, this was the proactive step we took – we must solve this problem by investing in research and devising a better process. We could not ignore the problem anymore.

Last year, our RSA (Resident and Student Association) leadership approached us with concerns they were hearing from their colleagues regarding the future of emergency medicine and particularly the role of Advance Practice Providers (APPs). Again, AAEM had to be proactive on this issue rather than being reactive. The board formed a task force to explore this issue and set a goal to draft a position statement. The task force worked hard and diligently to come up with a statement and the board agreed to take the proactive steps of issuing the statement and eliminating the allied health category of membership.

We published the statement and wrote an article explaining our stance. Again, social media blew-up in response, mainly positive responses from our students, residents, and attendings. Some APPs were concerned that we were attacking their titles, attacking them. Even APPs at my own program were concerned. What did it all really mean?

As AAEM outlined in our message to members, “These actions are not a statement against the great value of the properly supervised use of APPs in the emergency department, but a statement against the possibility of APPs being utilized to replace board certified emergency physicians.” It comes down to an issue of profits.

The first place they look to maintain profitability is in the composition of their workforce. An ABEM/AOBEM board certified attending physician on average makes over $190/hour as an independent contractor, an APP makes $50-$60/ hour. In terms of dollars, that is about the cost of three APPs to one attending.

We’ve seen this play out already — I’ve heard of CMGs replacing physicians with APPs or having one doctor supervising a staff of all APPs. In my conversations with APP colleagues, I’ve also heard the sentiment that, “We don’t want to practice alone, we want to practice together.”

I agree, when we practice together using a board certified physician-led team, it’s for the benefit of everyone. When we look at our flow, APPs practicing on their own: they see less patients, order more, and patient complaints rise. Especially when the patient received a $5,000-$7,000 bill for a cough and claim they were never seen by a doctor.

On this issue of APP independent practice, we have seen many states are either sponsoring a bill, have already passed a bill, or are attempting to pass one. These bills are not limited to granting independent practice to nurse practitioners or physician assistants, but also pharmacists, psychologists, chiropractors, etc. This is just plain dangerous and this is a patient safety issue.

The doctors who are sponsoring those bills, such as in my home state of Florida, claim no conflicts of interest, despite having an ownership stake in practices that would benefit.

AAEM does not oppose a joint team effort, what we do oppose is the independent practice of APPs without direct supervision by a board certified EM physician. One of our pharmacists recently said, “Wait does that mean I am out?” No you’re not out, rather you are a valuable member of the team, led by the board certified EM doctors.

Wait … did I say “doctor?” We should be more inclusive and all be “practitioners,” right? Wrong. Physicians earned our MD/DO after four years of medical school and the residency training that occurs after medical school cannot be substituted or lumped with any other group in the medical field.

On the topic of the title “doctor,” I’ve heard our Women in Emergency Medicine Committee saying, “what can we do to break the gender bias?” For far too long, women physicians are still mistakenly identified as nurses only and we often see our male nurses identified as the doctors. What do we need to do to change this? We all need to correct everyone and say that is Dr. Moreno not nurse Moreno. We need to be proactive and search out women speakers for our conferences, encourage women to join EM committees, and encourage more women to run for leadership positions. Yes, I am a He-for-She.

I invite all AAEM members to join me in this call to action — to shift our focus to being proactive rather than reactive to the issues that affect our day-to-day practice as emergency physicians. When we are passionate it drives us to become engaged, to learn, to educate. I encourage you to find your passion and join in advocating for the specialty we all love.


Addendum: In the Aftermath of the El Paso and Dayton Mass Shootings

In the aftermath of the mass shootings in El Paso, TX and Dayton, OH, on the same weekend there were multiple instances of gang violence paralyzing Chicago. Foremost, our condolences go out to all the victims, their loved ones, their families, and to the communities affected. Our thoughts are also with all the first responders, police, emergency department staff, EM physicians, trauma surgeons, surgeons, and the entire medical community.

This is a public health crisis and it is time that we all unite, despite our personal beliefs, and come up with actions. At this rate we are not
safe anywhere! The common theme of sending prayers without action are just motions to makes us feel better.

In Florida, there were 18 deaths were related to hepatitis A and a health crisis was declared, providing vaccinations and mandating vaccination changes. Yet, we have no funding for research for gun violence, the FBI does not even have a definition of what constitutes a mass shooting. People are still arguing if this is a public health crisis. It is not only a public health crisis, but an epidemic and with every epidemic, physicians are at the forefront. It is time to demand action, regulation, license, restriction, stricter background checks, and funding to study gun violence. Together we can fix this devastating epidemic and save lives. Thinking you cannot or will not be affected by this is just ignoring the problem until it is too late.


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