Letters to the Editor
As the editor of AAEM's bi-monthly newsletter Common Sense, Dr. Mayer welcomes your comments and suggestions. You can easily reach Dr. Mayer by submitting letters to the editor using the online form.
Note: All letters are subject to editing and approval by the Common Sense editor. All comments must comply with AAEM's Social Media and Antitrust Policies. No anonymous letters will be posted, unless pre-approved by the editor.
Disability and Life…Another Option!
I read with concern Dr. Borden’s article, “Disability and Life…Another Option!” in the July/August 2020 edition. Dr. Borden’s unfortunate experience, apparently with a company known for their aggressive sales techniques, should not be a generalization of the value, for many, of disability insurance / income protection. Since the likelihood of becoming disabled increases with increasing age, some policies may become more expensive and pay out less over time, although that is an uncommon structure. It is the buyer’s choice how they choose to structure their policy and any insurance professional should be able to assist in determining the relative value of an increasing or level cost. It is a simple breakeven calculation.
Dr. Borden’s difficulty in utilizing his policy when he became disabled is obviously concerning. A financial planner, some of whose clients will have experienced a disability, should have experience with various companies and recommend against inappropriately recalcitrant ones. Furthermore, companies can be researched in any number of ways, including looking up the company at the Better Business Bureau (www.bbb.org).
Dr. Borden is correct in that if you do not buy disability insurance but instead invest the money, assuming you are never disabled, you will have more money. But the same argument could be made of a car. If you do not buy a car, or instead by a cheaper car, and invest the money saved, you will have more money in the end. But disability insurance is not an investment account. It is protection of the asset…you!
Insurance is not, as Dr. Borden says, “gambling at a casino” but rather it is about spreading out low-probability, high-cost risk. It is not likely that a given emergency physician will become disabled at a specific time over a career, but some certainly will. For those that have, and are living on disability income, I suspect that they would have a very different perspective on the relative value of the premiums versus the benefits. If you are one of those unfortunate ones, who is going to maintain the household financial security while they are not working? Many EM physicians have non-working or much lower income spouses. How will they sustain the rent/mortgage, transportation, food, clothes, and all the daily expenses for the family? 25 years into a career, you may have well have enough savings to not require disability insurance and at that point, the value proposition may certainly be different than when you are a first year attending. But if you are injured one, five, or 10 years into your career, it is unlikely you will have already saved enough money to be financially secure for life. That is what disability insurance is for. I would be interested in hearing from someone who had to file a claim early in their career. From Dr. Borden’s purely financial analysis, surely, the amount they received would be greater than the amount paid in. More importantly, they had income (likely significant and tax-free income) when they otherwise would have had none.
There were many other points in the article to address: term life insurance, real estate investments, rental income, financial planners, investment fees, accountants, “own occupation” policies, and general financial planning. The basics are straightforward, but perhaps each should be addressed in their own column, or columns, rather than presenting them as alternatives to not obtaining disability insurance. Please, speak with your own team: financial planner, accountant, lawyer, or all of the above. If you do not have a team, start building one. How to build such a team is worth another column in and of itself. But talk to your team: if you cannot absorb the cost of having no income, then you have a need for disability insurance.
-Alex Flaxman, MD MSE
Fellow, Critical Care Medicine
Rowan SOM/Jefferson Health/Our Lady of Lourdes Health System
Note from the Editor
Common Sense appreciates thoughtful comments and ideas. Dr. Bordon's recent article concerning disability insurance has generated such a response from Dr. Flaxman. Sadly, medical education often produces young physicians who when completing residency are faced with much larger incomes and a new set of concerns for the financial security of their families. These same young physicians can be deluged with a plethora of advice of what to do to protect themselves and their families. This advice can be self-serving as many types of "financial experts" appear and make recommendations to sometimes unsuspecting physicians. This can lead to bad decisions, which can have serious long term financial implications. Dr. Bordon suggests a somewhat contrarian view in regards to insurance. His approach does require significant financial discipline and some would say an unacceptable risk to a young family. Common Sense hopes that you will consider both points of view and form your own informed opinion in this regard.
– Andy Mayer, MD FAAEM, Common Sense Editor-in-Chief
Dear Dr. Flaxman and Mr. Ruffing,
Thank you for your response to my article, “Disability and Life…Another Option!"
To answer the question as regards the quality of my policy, it was the best available at the time of my purchase. It was the number one ranked company.
During the midst of my struggle with the company (I can't risk stating their name since insurance companies are too huge and powerful to risk offending) I asked for a reference. I wanted to talk to an emergency physician that was receiving disability payments from them. I was desperate for hope, and concerned that there was really no way to get disability (short, possibly, of having no arms, no legs, combined with head injury). My response was; "No, I do not know of any emergency physician that is currently receiving payments." I asked three people with the company, and one (adjuster) stated that there was an EP that was applying after a serious motor vehicle accident, that would "likely begin to receive payments soon." Thousands of us paying for disability insurance, and NOT ONE OF US receiving payments. That was very disheartening.
Would I/you have any recourse against the second strongest political lobby in America? They could spend more than my (city's) entire net worth on lawyers against me and not even notice it.
Though I don't know the exact numbers, I am quite certain that over 99% of EPs would be better off using their money to create a liquid "rainy day account" than they would be after paying for disability insurance.
If you missed my article, please read it and comment!
- Mark Borden, MD FAAEM
Emergency Medicine Wellness Bill Of Rights
I loved Dr. Mayer’s article in May/June 2019 of Common Sense, “Emergency Medicine Wellness Bill Of Rights.” What could be better to bring to our loving democratic culture than an emergency physician bill of rights?
Somewhere along the near universal incorporation of EMRs into medicine, physician wellness seems to have tapered off. "Burnout by a thousand clicks," one study noting physicians spend more time on the EMR (40 percent),1,2,3 than performing direct patient care (30 percent). Have you ever received "the look" from a patient in discomfort or distress while you vigorously document? Meanwhile it's difficult for the patient to comprehend why the physician is surfing the web instead of delivering care. To compound our wellness woes, nearly half (47 percent) of emergency physicians report having been physically assaulted while at work.4
We as physicians should be entitled to a safe and respectful workplace. Somewhere in the course of residency training we accept that becoming an emergency physician means enduring no bathroom breaks, scarfing down food while hiding from administrators and patients in the crannies of the ED, and becoming a stoic wall to verbal threats as well as occasional physical violence.
While I don't think a physician bill of rights will cure all these problems, it is certainly a good start. Here are some items I’d propose:
- Ability to eat and drink in non-patient care areas in the workplace (without fear of the most recent Joint Commission, State, EMS, etc. audit of the department)
- A mandatory 10-15 minute break where you are required to leave the department to eat/pee/breathe
- Verbally abusive patients are subject to a medical screening examination and then in some fashion can be fired as a patient (they can return to the waiting room to wait for the next provider or they can leave)
- Mandatory scribe implementation; the EMR is here to stay, and until we reform healthcare to what truly matters, patient care and the unfettered ability to actually interact with patient, a strong assist is needed to be able to schedule additional time and remove the focus from itemized billing, most recent CMS measures (yes sepsis, I'm looking at you), RVUs, and of course data entry.
A safe workspace that values and protects its physicians is of utmost importance. The better we are able to care for ourselves, the better we will be able to care for our patients. Implementing a physician bill of rights might just be the start we need.
- Hill RG Jr, Sears LM, Melanson SW. 4000 clicks: a productivity analysis of electronic medical records in a community hospital ED. Am J Emerg Med. 2013;31(11):1591-1594.
- Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clinic Proc. 2016;91(7):836-848.
- Salyers MP, Bonfils KA, Luther L, et al. The relationship between professional burnout and quality and safety in healthcare: a meta-analysis. J Gen Intern Med. 2017;32(4):475-482.
- https://www.newyorker.com/culture/annals-of-inquiry/why-doctors-should-organize, accessed August 2, 2019.
- http://newsroom.acep.org/2018-10-02-Violence-in-Emergency-Departments-Is-Increasing-Harming-Patients-New-Research-Finds, accessed August 2, 2019.
-Brad Schwartz, MD
-Breanna Kebort, MD
Letter to the Editor
Dear Dr. Mayer:
My compliments to you, Dr. Jonathan Jones, Laura Burns, and the rest of AAEM’s staff on the new look of Common Sense. Great job! I was especially glad to see your editorials “Crossed Swords” and “What is ACEP Thinking,” and Dr. Lisa Moreno-Walton’s article “Thoughts on the Election of a Surgeon to the Presidency of ACEP.”
Even after I became a founding fellow of AAEM, I remained a member of ACEP, thinking I would do all I could for emergency medicine as a member of the Academy while I waited for the College to come around and start looking out for the interests of individual emergency physicians — meaning board certified specialists in emergency medicine. Unfortunately ACEP never did change course, and I finally gave up and resigned in disgust over behavior that convinced me ACEP had sold its soul to corporate interests — and had sold out both its membership and our specialty at the same time. I wrote the College and explained my action too.
Nothing seems to have improved since then. In the ensuing 20 years ACEP has granted fellowship status (FACEP) to non-board certified physicians (as far as I know the only specialty society in medicine to do such a thing), continued to elect upper management from corporate staffing companies like EmCare/Envision to leadership positions, and now even elected a president who isn’t a board certified emergency physician at all. Does the rank and file membership not know about these things? Do they not care? Do they not see the conflict of interest? Is it the lack of direct democracy that results in such decisions? I just don’t understand how this keeps happening. It’s bad for our specialty and all emergency physicians, whether we are members of ACEP or not.
That is why it is important that you and others keep the spotlight on ACEP. There is no telling what they would do if the Academy wasn’t around to compete with the College and criticize it when called for. Dr. Bob McNamara did a good job of pointing out how AAEM has made ACEP a better organization in the last issue of Common Sense, with his article “Where Would EM be Without AAEM?.” Please keep up the good work.
- Andy Walker, MD FAAEM
Corporate Head-Hunters: “Forgive Them, for They Know Not What They Are Doing…”
As Editor of Common Sense, I periodically receive information that becomes the grist for my next column in our newsletter. I recently received such a correspondence from Gary Gaddis, MD PhD FAAEM, one of the founding members of AAEM. I decided that it should be shared with our readers.
I don't know about you, but there seems to be an endless number of calls, emails, and messages that I receive at work and at home. Some of these are from “headhunters” for corporate management groups, looking for “bodies” to fill holes in schedules. How many times have you had those irritating interruptions, while working a busy shift, by a new unit secretary who “puts a recruiter through” to you? This seems to occur with the highest likelihood when you have been juggling details for multiple patients on a busy shift, right? Just what you needed, one more interruption!
One particularly persistent and aggravating company somehow has obtained one of my son's cell phone numbers, and calls him regularly. I am not sure if an infantry Captain is the person they need to fill “holes” in some contracted facility’s emergency physician schedule, but they seem to think so.
Does this circumstance sound familiar to you? Now let's hear from Dr. Gaddis, because he took such a communication, sent as a text message to his mobile phone, and turned it around in a manner that probably speaks for many of us. Gary wasn’t on anyone’s cross, as the title might imply, but I think the title of this column expresses the level of frustration some of us feel when we are contacted by corporate “headhunters.”
In December, Gary shared the following with me:
You may enjoy my response to a correspondence I have received from a TeamHealth “headhunter” and to which I have replied. I offer this for consideration for publication, for your column in Common Sense.
Sometimes, the opportunity to advocate for reasonable work environments and to try to educate those who work for employers that one could view as "ethically challenged" are just too opportune to pass up.
Let’s start with the text message that I have recently received from a recruiter:
Hi, this is Michelle (name deleted out of courtesy) from TeamHealth. I am reaching out to you to see if you would be interested in be part of our Emergency Medicine HIT Team working full-time within the Barnes-Jewish Hospital System. Located in MO and IL. We are paying $275.00 an hour plus travel expenses for a commitment of 120 hours per month. We have PRN rates available for less of a commitment. I look forward to speaking with you! Warm Regards, Michelle
Now, this hits close to home because I work in the BJC system, albeit at its academic "mother ship." I need to send this correspondence on to our corporate leadership, but that is a separate but related matter.
I am frustrated that the leadership of our system contracts with TeamHealth for its emergency physicians, and I am going to try to use my social contacts with our system leadership to try to educate them why TeamHealth is, in my opinion, not good for our system’s health.
Meanwhile, pending my setting an appointment to talk to the appropriate members of our leadership team, here is what I have sent to this "Michelle," who is probably just doing her job. I would guess that she is ignorant of the issues that led to my rejoinder, below, but here it is:
I would guess that you have a tough task, to find a doctor for this role, but I am not looking for Locums work and frankly, I know of too many doctors who have had adverse experiences with TeamHealth and similar physician staffing corporations, to be able to recommend any colleagues to you in good conscience. In your free time look up U.S. House of Representatives Bill 3267 re "Waivers of Due Process."
Due process is an important worker protection. I hope you have it in your employment contract. TeamHealth has a documented history of seeking Waivers of Due Process (WODP) by physicians whom they employ. Doctors who work under this onerous provision often feel constrained against speaking up, when hospital procedures represent a danger to patients' health.
You may soon learn of a "whistle blower" suit against a corporation similar to TeamHealth, EmCare, a corporation that has been absorbed within an entity called Envision. I understand that this matter is tentatively set to be tried in February or March of 2019. I have come on good authority to understand that the plaintiff has declined a six-figure settlement offered by the defendant corporation in that matter. Obviously, I am sworn to secrecy as to further details, but that which I state in this paragraph is fully factual.
Therefore, TeamHealth is radioactive to me. At least until they publicly renounce their prior practice of requesting WODP by their employed physicians, they will be on my "Do Not Fly" list.
If they have ever made such a renunciation of the practice of inserting WODP into their contracts, then I am as of now unaware.
Thank you for the opportunity to educate you a bit about ethical vs unethical corporate practices.
Gary Gaddis, MD PhD FAAEM
I think many of you would agree with the opinions Gary expressed in his text to the recruiter. I don’t think he was rude, but he was firm, and I think he responded to “Michelle” with a message that others of us might have texted, had we taken the time.
Happy New Year!
Time to Stop the Fake News
This past month, it has come to my attention that an AAEM board member has been presenting slides with ostensibly false information. A careful review of documents and policies demonstrate the slides appear to be clearly factually incorrect. I reached out directly to that individual. After a prolonged discussion, the individual agreed to remove the slides from his presentation but refused to apologize or correct his misstatements.
He rationalized this was justified because he believed the information was correct. He acknowledged he never checked. He stated he received this information from a former AAEM leader(s) but refused to acknowledge his source(s).
This responsibility to fact check before maligning colleagues or other organizations is amplified with each position of authority that person holds including their position(s) in the professional organization, their title and position of authority at their place of employment, and their role as an educator.
We must take action to decrease or eliminate the proliferation of “fake news.” Projecting one’s own beliefs onto another organization or culture as the identifiable enemy rather than focusing and weighing the positive and negative qualities results in “splitting” or “all-or-nothing thinking.” This proliferation of mistruths creates fear and mistrust amongst physicians, undermines confidence in our professional organizations and damages our specialty. Throughout history, this strategy has been employed by extremists and dictators to unduly influence the public. This proliferation of “fake news” is currently being discussed in multiple publications including Anti-Social Media and Weaponized Lies: How to Think Critically in the Post-Truth Era. Emergency medicine needs to elevate ourselves and stick to actual facts.
I am hopeful that AAEM will investigate incidents of this type and hold its leadership to the same accountability that other organizations do. Indeed, everybody should have “due process.” I am hoping the facts will be examined and that no one will be afforded any special treatment.
When leaders engage in spreading untrue statements and remain unchecked, the credibility of the entire organization is undermined. It is difficult to trust someone or work with an organization who won’t police their own leadership. It is disturbing when these leader(s) are called out, they don’t, can’t or won’t supply the evidence to support their assertions and refuse to apologize and justify their actions because they thought or wanted their statements to be true.
To me, integrity matters. Perhaps, I expect too much. I was taught to own my actions and when I make a mistake, I should work to correct it. I was also taught that if my mistake was potentially harmful, I should apologize.
Going forward, let this be a call for everyone to check their facts before making public statements about colleagues and other organizations, be transparent to the source of those “facts,” and be accountable for their actions.
It is time to end the divisive vitriol and restore integrity, accountability, and unity to our specialty.
– Paul Kivela, MD FAAEM FACEP, ACEP Immediate Past President
Note from the Editor
Common Sense appreciates members sending in their concerns and comments. Dr. Paul Kivela is a member of AAEM as well as the immediate past-president of ACEP. He sent this letter to the editor. It relates to a slide used during a recent presentation by Dr. Howard Blumstein a past-president of AAEM.
Common Sense represents AAEM, which is an open and democratic organization which supports dialogue and discussion related to controversies in emergency medicine and the concerns of its members. The differences between the goals and aspirations of AAEM and ACEP certainly can be seen as one of these issues.
Common Sense will print the slide in question, Dr. Kivela’s letter to the editor and the responses by Drs. Howard Blumstein and Robert McNamara. The staff of Common Sense hopes you will carefully read these and see what you think. We encourage responses to this series.
– Andy Mayer, MD FAAEM, Common Sense Editor in Chief
Response: What About Those Original Bylaws?
Dr. Kivela correctly points out that one of Dr. Blumstein’s slides on the content of the original ACEP bylaws is not completely accurate. I find the intensity of the criticism (extremists and dictators?) a bit unusual as the slide presents a favorable view of these bylaws. Of the five bullet points, the first two are largely correct and in comparing them to what was in the original ACEP bylaws we see a specialty gone astray from the vision of the founders. The first Blumstein bullet says “Members cannot take part of other member’s professional fees.” The original ACEP bylaws state, “In the practice of medicine a physician should limit the source of his income to medical services actually rendered by him, or under his supervision, to his patients.” I see no measurable distinction between these two statements. Clearly this is not the case today where we see EM physicians including national leaders and who derive all or the majority of their income from the labors of ACEP (and AAEM) members. This current division of fees would have been an ethical violation under the original bylaws. Today it raises the issue of prohibited fee-splitting where an EM pit doc is giving up 20% or so of their fees for the right to be put on a schedule to see patients (there is a huge class action sitting out there for the taking).
Let’s examine bullet 2, it states “Members should control their own practice.” The original ACEP bylaws say “the emergency physician shall not associate himself in any fashion with any institution that permits medical practice by other than a physician.” If that doesn’t speak against a lay corporation running your practice what does? This statement is the essence of the prohibitions on the corporate practice of medicine that exists in most states. These prohibitions simply state doctors should control their practice to avoid the business interest interfering with the physician/patient relationship.
These concepts have been held forth since the early days even before AAEM was founded in 1993. The 1978 President of ACEP, Karl Mangold, said in the specialty’s major journal: “ACEP and other professional societies and many state laws support the policy that earnings derived from physician services belong to the physician.” (JACEP 7:245-248). Mangold’s statement speaks directly to Dr. Blumstein’s first two bullets. That is a referenced fact, not fake news.
The other bullet points are incorrect in that the bylaws did not specifically mention open books or restrictive covenants. Additionally, due process is not specifically mentioned but there is a statement that EM physicians should be medical staff members equal to all other physicians. In case you haven’t looked, due process is standard for them and one can deduce the founders valued that. I was in grade school when the original bylaws were written but they look pretty darn good to me. In fact, if we threw in that all full voting members need to be board-certified I deem that original document as true to the principles of AAEM. It has always bewildered me how AAEM is labeled as “radical” when today it is closer to the original intent of the founders of ACEP than ACEP itself.
Certainly, I can agree with Dr. Kivela that unity among the physicians in our specialty would be ideal but that would require ACEP to join us in actively pursuing three of the bullet points Dr. Blumstein listed: no fee-splitting, no corporate control, and open books. The benefit to the pit doc would be huge if that did occur. I have always said simply having every EM doc see what is paid in their name would radically change the practice of EM as the bedside physicians would demand that we regain control of our specialty.
– Robert McNamara, MD MAAEM FAAEM, AAEM Past President
Since its inception, AAEM has had three core issues. The primacy of board certification in our specialty, economic exploitation of our peers, and unfair employment practices by those who seek to control our medical practice. It is that simple.
When I speak to young physicians, they are quick to grasp these concepts. They understand the financial motivations that drive those issues. They see how our colleagues enrich themselves, and their stockholders/owners, at the expense of those of us working in “the pits.” They feel the outrage that led to AAEM’s founding 26 years ago. It’s easy.
But then comes the hard part — where we must necessarily address how our specialty is dealing with those abuses. In what direction we are headed? And how do we have that discussion without including ACEP? ACEP is the elephant in the room. I don’t see how you can explain where we are going as a specialty without including the largest of the specialty organizations. That is obvious.
I always preface that discussion in my presentations by addressing the acrimonies of the past. I explain that I do not want to rekindle them. It’s too bad Dr. Kivela doesn’t give me credit. Conversely, however, when you talk about ACEP’s apparent lack of leadership on those core issues, it’s going to look bad. Because it is bad. It isn’t meant to be an attack. And I see a lot of heads nodding. Because it makes sense.
Audiences understand. ACEP continues to fill top leadership positions with never-been-board-certified doctors. How is that championing the importance of certification in our specialty? A disproportionate number of ACEP leaders are executives with, officers of, and/or equity holders in, contract holding corporations whose operation requires the exploitation and control of our peers. How can we expect them to formally and definitively push back against those abuses? We can’t. People get it.
Then the big finish. I tell audiences that ACEP really isn’t interested in me. I am too close to the end of my career. But ACEP is very interested in my audience — young physicians just starting off. In the audience sit people who will be members for 30-35 years. Future committee members, board members, and officers at state and national levels. Those are the folks both AAEM and ACEP want, or need. Of course.
Because of that, young physicians have power. I encourage audience members to exercise that power by asking direct questions of ACEP leaders. Why isn’t exploitation of our colleagues formally considered unethical? Why does ACEP make a statement of an emergency physician’s “rights” but then have no mechanism to defend those rights? Leaders of tomorrow should start demanding change today. It’s their future.
So the slide. I got rid of it even before Dr. Kivela called me and complained about a broad array of issues and people. I am not surprised by the vehemence of his letter. Ultimately the slide just did not fit into the flow of the talk or its ultimate theme. I still think the slide captured the spirit of the issue, although it has some factual errors. And I regret that. As I should.
Some folks respond poorly when I say “I think our core issues are the most important issues in our specialty. They are about professional and practice integrity and we are their champion.” It may well sting but that’s the way I see it, as do many others. I understand that we face many other issues. But how can we maintain our integrity as a specialty when violation of those core issues seems to be condoned through silence? We can’t.
One last thing. Someone please tell ACEP to stop sending me those “We miss you” recruiting letters. It would save them considerable postage. Obviously.
– Howard Blumstein, MD FAAEM, AAEM Past President
The Academy and the College
Thanks for your strong yet fair response. I have been an AAEM member since residency and an ACEP member as well. I have served in various roles with both. I did not know about the Florida issue or the support of BCEM by ACEP, however. I am going through some personal issues with my academic employer that is looking like it will result in a career reset so the maltreatment of EPs is palpable for me on a global and personal level. In fact, in confidence, it is ironic that my possibly final act was to re-write the credentialing requirements for my subspecialty. Anyway, I wanted you to know that I completely agree with your comments and believe it was fair and balanced. I am sickened by what I have witnessed over the last few years. The issues are not only with the contract management groups but also with large academic hospital groups as well. In these groups one also sees lack of due process, restrictive covenants, lack of transparency, and all the same issues
raised for years with the CMGs. Employed physician groups of large hospitals and hospital systems are the new CMGs. I am not sure what I will do about my ACEP membership next year, but I know I will still be working with my AAEM colleagues without a doubt.
— Name withheld by request
Thank you for both your kind words of support for me, and more importantly, for your support of AAEM and its principles. I believe your story is important and our specialty would benefit from its telling. I think you should seriously consider writing your story anonymously for publication in Common Sense. I thought academic jobs usually provided for some kind of peer review and due process and were free of restrictive covenants. I was surprised to read,
"I am sickened by what I have witnessed over the last few years. The issues are not only with the contract management groups but also with large academic hospital groups as well. In these groups one also sees lack of due process, restrictive covenants, lack of transparency, and all the same issues raised for years with the CMGs. Employed physician groups of large hospitals and hospital systems are the new CMGs."
I knew of the lack of transparency in academia — and of the dean's tax taken at multiple levels — but not of the other issues. If I am ignorant of these problems in academic emergency medicine, I guarantee you that most AAEM members are too. We will remain ignorant until someone with direct experience explains the situation. Please think hard about being that person.
— The Editor
Physician Burnout or Physician Resiliency
After reading the article titled “Physician Burnout or Physician Resiliency?” I have come to the conclusion that the issue of physician burnout will not be solved without completely revolutionizing the way our profession views the problem. Most proposals look at the problem of physician burnout as a physician problem. The article adds to this myth by identifying resiliency on the part of a physician as a solution. Such solutions simply continue to enable failure by decision makers in health care by giving them the tools to maintain the status quo and act as if something is being done to address the issue.
The reality of emergency physician burnout is that it is a workplace issue caused by a number of factors: understaffed emergency departments, difficult to use electronic medical records, slow computers and networks, unresponsive consultants, the misapplication of customer service based management philosophies, and malpractice issues. Undoubtedly there are others.
If factory workers suffered from poor morale because of an unsafe work environment, no one would recommend that they be more resilient. OSHA would mandate that the issues be corrected and management would see that it was done. Until we come to see physician burnout as a natural response by highly skilled, motivated, and intelligent individuals to workplace safety issues, nothing will change.
If you are feeling burned out, it’s absolutely essential to realize it’s not a “you problem.” Your hospital is what is falling short. Most emergency physicians lack the ability to make even the smallest of improvements to the environment they work in, so voting with your feet is the absolute best thing you can do to address burnout and secure your future career. When you do, following the three guidelines at the end of the article will help you in your search.
— Milind R. Limaye, DO FAAEM
First, thanks for writing. I love hearing from readers of Common Sense and wish more would write. Second, I couldn’t agree more with your statement, “If you are feeling burned out, it’s absolutely essential to realize it’s not a ‘you problem’. Your hospital is what is falling short. Most emergency physicians lack the ability to make even the smallest of improvements to the environment they work in...”
As I pointed out in “Responsibility and Authority” in the July/Aug 2014 issue of Common Sense, because so many emergency physicians have lost control of their departments and lack any authority to change or improve them, but are still held responsible for what happens in them, they work in an environment designed to create what psychologists call “experimental neurosis” and cause burnout. Every case of emergency physician burnout I have seen in my over 30 years of practice was caused, not by some character defect or psychological flaw in the physician, but by a pathologically defective work environment that was created when control of the ED was taken away from the doctors and nurses who care for patients there, and turned over to bureaucrats and administrators. When good doctors are put in an environment where they are prevented from delivering the best possible care as efficiently as possible, they become frustrated and unhappy. When they are held responsible for the flawed department that was forced on them and that they are powerless to change, or harassed over meaningless metrics that distract from actual quality, they burnout. The fundamental truth about burnout is this: burnout is the normal response of a good emergency physician to a malfunctioning ED, when that physician has none of the authority needed to correct the malfunction, but is held responsible for it. If we want to reduce physician burnout, we must restore physicians’ professional autonomy.
— The Editor
Crossing the Line
Hi Dr. Walker!
I am just a regular old ER doc trying to make a living, and a proud AAEM member who has really enjoyed the editorials regarding CMGs, particularly those regarding EmCare and Rebecca Parker.
I experienced Rebecca Parker and EmCare first hand while staffing Lake Health as a locums during the very time period you have written about. While advocating for myself, my patients, and my reimbursement, I was called names by EmCare directors, and Dr. Parker herself threatened my livelihood if I failed to comply with her edict of signing out and not billing for a minute over the shift unless performing critical care in a single coverage setting.
It’s been over 7 years now and I have managed to survive without EmCare, TeamHealth, ApolloMD, or Schumacher. I refuse to staff their contracts. I encourage any doctor I meet on the circuit to avoid them. After many discussions, a few major locums agencies also finally decided to cut ties with these companies, because they grew weary of vendor practices and companies claiming doctors and invoking 5 year non-competes.
I find it distressing that someone wrote about all this in 1998 in the now famous The Rape of Emergency Medicine, and yet ER doctors did not heed the warnings. I am only one person, and the effect of my personal black list is not far reaching. What can be done about the harmful effect these companies have on our specialty and patients?
I am willing to serve.
— Name Withheld on Request
Thank you for writing. I regret that we live in a world where you had to ask us not to publish your name, but I understand the reasons for your request. As for your question on what can be done about the corporate staffing companies that prey on emergency physicians, I don't know what else AAEM can possibly do. The Academy does all it can to give emergency physicians the knowledge they need to protect themselves. It takes legal action whenever appropriate, feasible, and cost-effective. Now it has even formed the AAEM Physician Group (AAEM-PG), to support democratic independent groups and found new ones. The only avenue the Academy hasn't yet pursued is forming a union to protect those emergency physicians who are employees — and I'll bet that will happen in the next few years.
As for individual emergency physicians, all they can do is have the moral fiber to refuse management positions in companies that treat their colleagues unfairly. To our specialty's credit, and our profession’s, most do. But it takes only a small percentage of emergency physicians willing to violate their professional ethics to keep the contract management industry running.
That brings us to the real question: what more can ACEP do? Those EPs who are members of ACEP should think long and hard about that question, and take it to ACEP leaders like President Rebecca Parker. And they shouldn't accept fears of violating antitrust laws as an excuse to avoid the issue — because that is a lie. If antitrust laws were a legitimate concern in the effort to protect individual emergency physicians from predatory exploitation, the feds would have come after AAEM 20 years ago.
— The Editor
Crossing the Line II
Reading your editorial in the September/October issue, you discussed CMG travelling docs (special ops, the hit team, the strike team, etc.) and you discussed how they make it easier for a CMG to attack and take over emergency departments. Often those “special ops” guys and gals are the ones that make it easier for a CMG to steal a contract from a long-standing independent and democratic group or from another CMG. This is a fact.
There is something else, however, that you didn’t touch on: special ops physicians make it so much easier for a CMG or hospital administration to deny physicians due process.
I know because I used to be a special ops physician for a CMG long before the term “specil ops” was even invented. Early in my career, I worked for a medium sized CMG (that is now a large CMG). It was a frequent occurrence that I would get a call that a certain ED needed someone urgently and that they would pay me an extra amount to go cover a shift or group of shifts.
I usually would get to that hospital and realize that someone had been “taken off of the schedule.” As a young and slightly arrogant physician, I would be proud that I was called in to cover for the “less than adequate” physician.
Nowadays, I regret that I was ever used that way and I regret that I was part of the process. I now realize that almost all of the physicians that I replaced at the last minute were denied due process. I am ashamed of that.
Due process is important. It is important that we stand up for each other. If you are reading this letter and you are a special ops physician, think about it.
— Terence J. Alost, MD MBA FAAEM
Thank you for writing. You make an excellent and important point, one I had not considered. I hope our colleagues who now fill your former role will think long and hard about the ethics of what they are doing and how it effects our specialty.
— The Editor
The Moral Arc
I just read your message in the recent issue of Common Sense. I have to say I have grown tired of the ACEP-bashing abundantly reproduced from AAEM's leadership over the years. You stated, "I want you to clearly understand the differences between the Academy and the College." Then, your examples imply ACEP must be on the side of corporations. Further, leadership of or even employment by staffing corporations, by default, means ACEP and its leaders must not be looking out for the individual physician. Not a "fair and balanced" description and one that does much to perpetuate the divide between the Academy and the College.
Interestingly, as I read through the rest of the magazine issue, it is apparent ACEP and AAEM share most of the same issues, direction, and priorities. In fact, I have noticed these similarities over many years.
I truly appreciate AAEM's desire to preserve the ideal work environment for the individual emergency physician. Indeed, that is why I have maintained my AAEM membership for over a decade. I have only ever worked for independent groups, aside from my time on active duty service with the US Navy. I would prefer to keep it that way.
With that being said, ACEP-bashing always points to some past or current leaders within ACEP who have been leaders or employed within large contract management groups. However, this "guilt by association" assumes some sinister plot to take advantage of individual physicians. I have not witnessed that to be true. Through the Florida chapter of ACEP, I had worked for years alongside a physician from another part of the state before it ever became known to me that he is a senior vice president with EmCare. Whenever he spoke, he always spoke with the individual physician's best interests in mind. I never heard him speak on behalf of EmCare or corporate medicine, for that matter.
In fact, most of the people I know today who work for CMG's, as well as many of the partners I have worked with in independent groups, want nothing to do with the business of emergency medicine. They want to clock in and clock out, get paid and leave the rest to someone else. Surely you know this type, also. However, no group would survive if it did not tend to the business of emergency medicine. The business of EM has costs and even a small group will find it needs to allocate some "administrative time" for their leaders in order to manage this business. I have not found a group where these leaders are willing to do so for free, on their own time, and only be compensated for the clinical work they do.
Yes, I don't want to be taken advantage of by any group skimming off the top of my hard-earned revenue just to line their pockets. Yes, I also recognize I will be required to contribute to the costs of billing, liability insurance, and "management" of my group.
I am happy to see AAEM maintain its principles of looking out for the "little guy." ACEP is hard at work for emergency physicians but does not become involved with contracts between a physician and their employer or group.
Yet, continually detracting from ACEP as an organization, and ACEP's leadership simply because of who they work for rather than what they say and do, has grown tiresome and seems out of touch with the ACEP I know well. The two organizations could do so much more if they worked together on common issues currently being tackled independently.
I implore you and AAEM's other leaders to simply agree to disagree with ACEP on some issues and to work together on others. No family exists without some differences of opinions on how things should be done. But, in the end, we are all the same family and can succeed together if we will work together.
— Steven B. Kailes, MD MPH FAAEM FACEP
Thank you for writing. Your criticism is rational and articulate, and I appreciate the time and thought that went into your letter. In fact, your letter is so well done and on such an important topic that I have decided to devote my “From the Editor’s Desk” column in the Mar/Apr issue of Common Sense to replying to it and explaining my position.
— The Editor