Issue: July/August 2022
Author: Jonathan S. Jones, MD FAAEM
In my last article in Common Sense, I explained my goals for the Academy and my plans to accomplish them. And while I explained some of the things which I love about emergency medicine and some that I don’t, I didn’t really explain why I joined the Academy in the first place. Two recent, yet completely unrelated events reminded me why I joined and have motivated me to work even harder for the Academy.
Event #1: I was Fired
Exactly one week after becoming President (and one day before my daughter’s birthday), I was fired by the CMG for which I primarily worked. My contract had a stipulation for termination without cause given 90 days’ notice. I was given that notice on May 4. I made sure to clarify if I was being fired with or without cause and it was communicated that it was without cause. I asked if there were any concerns or specific reasons I was being fired. Specifically, I asked if there were questions on my management of patients, if there was a threat of a lawsuit, if my quality or patient satisfaction metrics were subpar, if I was not seeing enough patients per hour or charting appropriately. I was told that it was none of these. It was simply “a staffing decision.” That decision was that the current 11a-9p shift, no longer required a physician and it was being transitioned to be staffed by a non-physician practitioner (NPP). I then asked why specifically I was being terminated, given that two physicians working at that facility are not board certified. I was simply told, without further explanation, that it was for other reasons. I actually took that as a compliment.
At first, I thought that I was being singled out, that this was a special case. But within seconds I realized that it was not a special case. In an odd way, I wish that I was special. I truly wish that the above is so odd and exceptional that everyone reading would be shocked that something like this could happen. Unfortunately, I know that that none of the above is truly surprising. This is routine. Residency-trained, board certified, emergency physicians are being fired every day. We are being replaced by lesser qualified clinicians. And the decisions to do this are made by individuals with no medical training nor any ethical obligation to patients. Why?
Well, for the same reason nearly everything is being replaced by inexpensive copies. Or actually, why there is a substitution or imitation version of nearly everything. I recently took a brief family vacation to Savannah, Georgia (which is a beautiful city by the way and one in which we may try to host a future meeting). We had arranged a boat rental to see some dolphins, explore a little, and enjoy quite time away from the city. I realized that I forgot to pack any sandals. Oops. Luckily, I found a very tacky beach store and was able to buy a pair of sandals for $9.99. They fit perfectly, were actually comfortable, and performed their job well. Seventy-two hours later, they were falling apart. I wasn’t upset in the least. I knew what I wanted and I knew what I had bought. I simply needed sandals for a boat and beach excursion. I had nice sandals at home. I didn’t need a replacement and I didn’t need any fashion sense. With full understanding of the situation, I purchased a pair of inexpensive sandals. I voluntarily entrusted my feet to this obviously inferior piece of footwear.
The point of my analogy is that I was informed about my options and I consented to purchase and wear inexpensive sandals. I was effectively provided with informed consent and freely made the choice which was best for me in that situation. Yet, for the infinitely more important decisions about our health, no such informed consent takes place. Neither the hospital nor the CMG has provided any notice or informational post to the patients about the impending changes to the quality and experience of those who will treat them in the emergency department. Nor have I seen any forms for patients to consent to receive care from clinicians not trained in emergency medicine.
As we know, the root of this problem is multifaceted. First, especially in the emergency setting, patients are often critically ill, scared, desperate, or otherwise in need of immediate care. They are rightly more concerned that someone, some human being, is there for them. In their time of need, the credentials of this person are of secondary importance. Second, credentials can be misleading, sometimes purposefully so. What exactly is a “doctor?” Add to this the alternative boards as well as NPP “residencies” and it can even be unclear what “board certified” or “residency trained” means. Third, while all decisions about purchasing my sandals were completely within my control, very few decisions about receiving health care are within the patient’s control. While this particular beach store did make the decision on what to stock, they clearly advertised the type of products they had and I made the decision on which store to use. However, while hospitals make the decision on which products to stock, i.e., which types of physicians or non-physicians to employ, they rarely advertise this. And worse, patients are often told which stores (hospitals) they may or may not use by their insurance companies.
Finally, and most importantly, the product we provide is complex and literally life-saving. Yet, our skills are not acknowledged. Hospital and CMG executives are trained in business school and view the physician as any other commodity. And while it is true that every single employee is valuable, it is also time to stop being so politically correct and humble. Physicians are special. We are different. The entire organization revolves around the skills we possess and the care we provide.
Above I named only four problems. There are many more. And while the solutions to the above problems are not easy to accomplish, they are actually simple. We need to educate patients. We need to ensure clarity about titles. We need to insist that hospitals and insurance companies clearly inform patients of the qualifications and expertise of those providing their care. Similarly, we need to ensure that hospitals and insurance companies understand the value that we provide. And yes, that does not only include the value to patient care, but also the value to the bottom line.
I am grateful to past AAEM leaders, board members, committee members, and others who have worked on these issues. We have made tremendous progress but we are not nearly done. Only when patients begin to demand care from true specialists in emergency medicine will the current trend change.
As president, I am, and will continue to look for ways that we can educate the public about the qualities and qualifications which differentiate a Board-Certified Emergency Physician from everyone else. AAEM is already partnering with multiple organizations on this task and I will continue to explore new opportunities for collaboration. This includes seeking partnership with nurses, NPs, and PAs.
I feel that nurse practitioners, PAs, and others play a vital role in providing patient care throughout the house of medicine. I personally know several whose presence in the emergency department only improves the overall care provided. In one of my previous roles, one of my most valued partners in the ED was a pharmacist. We physicians are not experts on everything. The ED pharmacist knows more about exactly which medications will interact with Paxlovid than I do. My NP colleague knows more about routine diabetes management (which many of my ED patients require) than I do. My ED nurse colleagues have specific knowledge and innumerable skills which I do not possess.
On a recent night shift, we were woefully understaffed with nurses in the ED. This resulted in me performing some otherwise routine nursing tasks. It was horrible. I suffered. More importantly the patients suffered. Not that I didn’t already know it, but I cannot replace a nurse. I do not possess the specialized knowledge and skill set required. Likewise, a nurse cannot replace me unless of course some business person one thousand miles away says so.
What I’m getting at is that we need to clearly define our allies. The NPP replacing me at this hospital is likely not my enemy. Most NPPs with whom I’ve worked don’t actually want complete independent practice. Yet, they are being told by their professional organizations that they should seek this. They are told by hospital administrators and CMG regional directors that they are capable of this. They are told by their schools that despite the fact that they had to arrange all their own rotations and that none of their preceptors are actually vetted or reviewed, they are equal to a physician.
Many if not most of you reading this message work with NPPs. Ask them if they are happy with the proliferation of NP schools with low standards, online-only instruction, loose accreditation, and preceptorships without any oversight. I have, and I’ve yet to meet one NPP who feels this is appropriate. I’ve even had one talk to me about the NP workforce issue and the fact that the supply of NPs now far exceeds the need and yet more NP programs are opening. Sound familiar?
Are there unethical and dangerous NPs and PAs? Ones who purposefully confused patients about their training and qualifications? Ones who feel their education is truly equivalent to that of a physician? And ones who despise any type of collaboration? Yes, there most certainly are. These are dangerous individuals and they should be called out. However, this does not describe the typical NPP which I have met.
Similarly, are there physicians who practice out of their scope in the ED? Are there Board-Certified Emergency Physicians who manage CMGs, sign sham agreements to “own” independent groups, and who dictate staffing levels without regard to patient safety? Yes, there are and they are dangerous individuals as well and should be called out.
Our allies are all those trying to provide the best possible care to patients. Our enemies are those trying to confused and exploit patients. If the public at-large is to truly have informed consent about their medical treatment, it is going to take more than just our Academy. Therefore, similarly to partnering with organizations to educate the public about the qualities and qualifications of an ABEM or AOBEM Physician, I will work to partner with non-physician allies who believe in our mission statement.
In case you’re wondering, being fired has so far worked out rather well. I will now be working half-time at a more convenient hospital as well as doing Locums Tenens at a few locations in the state. (Do you know about the Academy’s own Locums Group, AAEM-LG?) My schedule is better than it has been in years. It has also reminded me why I joined the Academy. I joined because bad actors are exploiting good doctors and endangering patients. Someone has to do something about this. That someone is the American Academy of Emergency Medicine.
Event #2: The Supreme Court did Some Stuff
Multiple impactful decisions have recently been made by the Supreme Court. Nearly the entire country is talking. Some are happy, some are upset. The discussion about these momentous rulings also reminded me why I joined the Academy. I joined because I saw the Academy as an organization which could bring a diverse group of physicians together with one single focus—to improve the ability of emergency physicians to practice medicine. While I may personally have opinions on the Supreme Court decisions, none of that matters for the Academy.
The Academy should be a “safe space” and a place for us to share our opinions and have an opportunity for dialogue and to learn from one another. For the good of the Academy and for our profession, I don’t care if you are pro-life or pro-choice. I don’t care if you are an NRA member or an advocate to abolish the Second Amendment. I don’t care if you voted for Donald Trump, Joe Biden, or Jo Jorgensen (Who? Yeah, I’m not a fan of the two-party system). But I also don’t care if you love the two-party system.
I care that you have dedicated your professional career to be exceptional in the practice of emergency medicine. If you want to practice medicine without interference from corporate groups, then I care about you. If you are burned out and frustrated because of the limitations placed on your ability to practice medicine the way you see fit, then I care about you.
For the Academy, I will be focused on what we do. Until I see AAEM Physicians Group vs. Envision Healthcare Corporation on the Supreme Court docket, then as far as the Academy is concerned, the Supreme Court doesn’t much affect us and I won’t let any ruling stop me from pursuing the goals that I have set for myself as President.
Let’s stay focused, let’s find allies, let’s fight, and let’s win.