Letters to the Editor

Letter to the Editor - Dr. L.E. Gomez

A note from Dr. Gomez: I am responding primarily as a mentor to Jada Watts and myself and not on behalf of the AAEM Board or JEDI.

Public discourse on race is challenging and, at times, emotionally charged, so let me begin by stating that I loved my white grandmother and black grandfather equally.

The article referenced in Dr. Andy Walker’s letter to the editor is one I co-wrote with my mentee, Jada Watts, a second-year medical student at Howard University College of Medicine, an HBCU where I was formerly an associate professor.

Disappointingly, it seems Dr. Walker disagrees that we all carry implicit biases or can improve our ability to live up to our AAEM Mission of reflecting justice and equity by being aware of our biases. It makes me wonder if he read the article critically or dismissed it based on the coincident skin color of its authors.

It is clear he believes he’s being labeled a racist by its content and compares that to being called a pedophile. The article did neither of those, yet his letter to the editor reflects discomfort and defensiveness based on his self-perceived race. Our statement in the article that we all hold biases could not be clearer. It is almost as if Dr. Walker intends to foment divisiveness by distinguishing himself as “white” even though I never use the word white to refer to race or distinguish between myself and any other emergency physician based on the color of our skin.

I hope this clears up his first question. At the top of our article, I state that we are all affected by falsehoods about what we are taught about the inferiority of POC and specify that “we are all aware race is a social construct and there is only one that should be relevant to emergency medicine specialists: the human race.” I leave it to readers to decide if Dr. Walker, who I have been on a first-name basis with along with the rest of our leadership team for years, is being pejorative by referring to us as “Watts and Gomez.” I know it’s common in the military when a superior is addressing an inferior, but Andy and I are contemporaries and with almost identical credentials and years in practice and so he must be aware we are at a minimum, equals, professionally speaking. As such, we both know how to access the reference section of an article to review evidence regarding content such as that “we hold these biases.” The word “we” refers to all of us, equally, Dr. Walker.

As for Dr. Walker’s self-reported attitude and what he has seen in his career, I expect Jada will not be reassured by his comments, but rather, more concerned, given that her brother’s life was lost to gun violence and some of us have no idea what is like to suffer being discriminated against based on the color of our skin at any time let alone in such a critical and painful situation.

In my 30-year career, I have seen and met emergency medicine specialists that are humbly compassionate regarding cultural competence and others that arrogantly believe they are doing minority patients a favor because they agree to take care of them at all. Our current AAEM BOD has updated our Mission Statement to reflect humility and pledge to ensure we are all committed to providing compassionate, equitable care to all our patients. ABEM is developing requirements for cultural competence in emergency care. ACEP and the AMA have policy statements that specifically assert sensitivity to racial bias in practice. Admitting our biases is not tantamount to an accusation, it is a humble admission of shortcomings we all are subject to, and Dr. Walker should rest assured that we have many friends and allies in this process, not only in AAEM but in the house of medicine, not only in our country but the entire world, regardless of the color of our skin.

– L.E. Gomez MD MBA FAAEM

Editor’s Note: Dr. Gomez and Ms. Watts’ original article ran in the March/April issue of Common Sense (page 45). Dr. Walker’s Letter to the Editor ran in the May/June issue of Common Sense (page 8). Please visit aaem.org/resources/publications/common-sense.

Letter to the Editor - Dr. Andy Walker

For many years now in the United States, one of the worst possible accusations that could be made about someone is that they are a racist. It is right up there with pedophile. Imagine my surprise, then, to find myself and other emergency physicians labeled as racist by two of my colleagues, Watts and Gomez, on page 45 of the March/April issue of Common Sense. First of all, it isn't clear if they are accusing all emergency physicians of racist bias, or just the white ones. If the latter, neither author knows me (or every other white member of AAEM) well enough to accuse me of racism based on my own individual behavior, and isn't judging an individual based on nothing more than the color of his skin the very essence of racism? Second, and more substantially, big claims demand big evidence.

So, what evidence do Watts and Gomez offer for their accusation that, “There is no doubt we hold these biases”? The only evidence they offer is “the now famous Harvard IAT (implicit association test).” They claim that IAT results prove that “we are all frail with regard to holding biases, particularly when considering our propensity to believe in such falsehoods as the inherent inferiority and threat of people with brown skin.” They also say, “Go ahead and take the Harvard IAT and fearlessly accept we all hold implicit biases.” However, the IAT is controversial and has not been proven to be a valid or reliable indicator of individuals prone to racist behavior.1-9 I am disappointed and surprised that emergency physicians would rely on such an unsubstantiated test to accuse their colleagues of something so horrible as racism.

Finally, based on my own attitude and what I have seen from every other emergency physician I have encountered in the course of my 36-year career, I can offer Ms. Watts some reassurance. She says that when her brother suffered a gunshot wound she was worried his doctors might see him as “a black thug” and that would affect the quality of his resuscitation. We emergency physicians have freely chosen to take care of everyone, without regard to their race, gender, socioeconomic status, or even character. Whether the patient is a saint or a criminal, we do our best for everyone. Not out of personal affection for a specific patient, because we rarely know our patients, but out of our pride in and commitment to excellence, and commitment to the ethics of our profession. That is a far more reliable motivator than our personal feelings towards any individual patient. You can rest assured that your brother got the best his emergency physician could give.

I am all for “justice, equity, diversity, and inclusion.” However, justice means justice for all, and making blanket accusations of racism without any basis in fact and without offering substantial evidence is horribly unjust. And from a more practical point of view, it isn't a tactic that wins friends and allies.

Andy Walker, MD, MAAEM

COVID Reimagined

As an ED physician in the current COVID pandemic, we are told that once you are vaccinated you should continue to social distance and wear masks.

Even though we are told the present Pfizer and Moderna vaccines confer 95-97% immunity we should continue these measures as we may still be conduits to spread the virus to others not vaccinated.

At the same time, we are worried about changes in the virus such as the UK and South African strains, which may decrease our immunity and again make us susceptible to re-infection.

What we KNOW is that presently we are at least partially protected from infection from any strains if we have been vaccinated.

By preventing re-exposure to these strains now, we are insuring that eventually when our immunity wanes we will be susceptible to these re-infections.

Now is the time when we, who are vaccinated, and have adequate antibody levels to resist infection of the COVID-19, to not avoid but rather boost our response to new variants.

Contrary to conventional wisdom, I would encourage those with full vaccinations to go out without masks and social distancing to be exposed to the new variants while we have full or at least partial protection from our vaccine. Perhaps then we could avoid a resurgence of a new strain in the future.

– John V. Murray, MD FAAEM

 

Disability and Life…Another Option!

Dear Editor,

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

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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

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Response

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.

References

1. 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.
2. 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.
3. 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.
4. https://www.newyorker.com/culture/annals-of-inquiry/why-doctors-should-organize, accessed August 2, 2019. 
5. 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
Cheverly, Maryland

-Breanna Kebort, MD
Baltimore, Maryland

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.

Thank you,

- 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:

Dear Andy, 

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:

Hello Michelle: 

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!

-Andy

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

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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

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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

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Response

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

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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

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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