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.
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
Who Cares About Due Process?
I have practiced emergency medicine since 1986 and had planned to continue to practice for another 4 years. This article was almost too personal. ABEM certification was established in 1980 with re-certification mandated every 10 years. Continuous certification was established by 2000. I am sure ABEM thought that rigorous testing would bring credibility and respect to our specialty. I cannot speak about what happens in academic centers, but I certainly can confirm that emergency physicians are the stepchildren of the hospital. It has nothing to do with competency. The medical staff is often rude, and if the right buttons are pushed by the medical staff, nursing, or administration, the ED medical director is summoned to the CEO's office.
He or she is told to dismiss the ED staff physician who has somehow attracted the anger of someone in the hospital. And the CEO holds the director hostage by threatening to terminate the contract. Thus the ED physician is abruptly terminated.
Up until the last year, if I left an ED position, it was my decision. I have been terminated four times since then, but let me elaborate. I was terminated after 4 years at a hospital in Houston when a new CEO was named. I was quite vocal about lack of equipment. We did not even have an oto-opthalamoscope in every room. The nurses were incompetent and had no clinical experience. The medical staff never came into the hospital at night when one of their patients would crash and burn. I came back to Houston at the end of a one week vacation in March and found that I was not scheduled for April. That is how much notice I received.
It isn't rocket science when an ED physician starts at a new facility, that there is a learning curve, because every hospital runs their department differently. A two week grace period to adjust was more or less accepted. The introduction of computerized medical records changed all of that.
I have been exposed to four different ED computer programs. The learning curve for each ED physician is variable. However, these programs take away valuable patient time. The expectation in my experience (and I was actually told this) is to shot gun lab and radiology. How do you know what to look for if you haven't done a thorough history and physical? The following is an example of one of my short-lived jobs: the ED director sat outside the exam room while I was working up a new patient, and timed me. My maximum time allowed was four minutes. That is a physical impossibility.
My last few jobs have lasted 4 days, 3 days, and 3 days respectively.
Can any ED physician come into a new department and reach maximum efficiency within one or two days. So much for fairness and due process. That would never happen to a staff physician. In fact, it takes an act of God to get an incompetent staff physician off staff.
I am still at the top of my game. ED physicians used to leave the profession because of burn out from shift work. Now I expect that our specialty will reach critical mass because respect by the hospital staff has reached an all-time low.
For me, the handwriting is on the wall. I can only take so many punches. If AAEM does not take a leadership role in ending a very disturbing double standard, the public will be seeing unqualified primary physicians when they are critically ill.
— Evan B. Tow, DO FAAEM
Dear Dr. Tow:
Thank you for writing. It takes courage to tell a story like yours. Unfortunately, your story is not unique — it isn’t even unusual. I promise you that AAEM is doing everything possible to assure that emergency physicians have the same due process and peer review protections as all other members of the hospital medical staff. Our progress has been slow, however, largely because so many with deep pockets want to be able to get rid of emergency physicians without any inconvenience — and because the Academy is fighting this battle with little or no help from other professional societies in emergency medicine.
Please hang in there and keep trying. You might consider an academic job or even look into nontraditional ways to practice emergency medicine, such as critical access hospitals; VA, military, or American Indian reservation hospitals; overseas practice settings; or locum tenens. There are lots of hospitals out there that are desperate for board-certified specialists in emergency medicine, and there are still hospitals and EDs that care more about quality, patient welfare, and doing the right thing than about speed and metrics.
— 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
The Moral Arc II
I have been an emergency physician for 20+ years and have worked under a number of models with various groups. I must take exception to the oft-stated position among AAEM leaders that CMGs are somehow more vile than privately run contracts. I offer my personal experiences, admittedly unscientific with an N of 1, but very real. I will not name specific physicians, groups or cities, but they know who they are.
One private group recruited me after they had already been given notice of termination and had me scheduled the very last week they had the contract to staff the ED and never said a single word to me.
Another group strung me along on a 'partnership' track but the founder maintained a 51% controlling interest and overrode the group's recommendation to let me join, without a reason. I quickly realized he intended to retire and did not want to split the profit. As I suspected, he retired and left the group with no succession plan and they were forced to become hospital employees at 35% lower pay. Fortunately, I saw the writing on the wall and had already left.
Yet another group had a fee-for-service model where a flat rate was paid until collections caught up. After a few months, the 'open books' were not reflecting my productivity accurately and I was told there wasn't anything more to be paid. The rest of the group received the largest bonuses ever. Obviously, they were skimming my productivity. I resigned, giving my 90 days notice and even still covering a holiday before leaving. 3 months later, I received a $13,000 bill for tail coverage. If I had simply walked away and quit, they would have had to pay. But because I was honorable, it wasn't covered.
Also, another independent contractor group suddenly decided we needed to be 'on-call' several days per year because other physicians were calling off on weekends and holidays and it was difficult to get coverage. Of course, no incentive was offered to pick up those shifts and there was no compensation for the time we were expected to be available for a last-second call-in. My time away from work is just as valuable as time at work.
Clearly, private groups are often just as unscrupulous as any national CMG. Many of these same small groups sell out their practices to CMGs and pocket handsome profits by a tiny part of the groups' management and leave the rest to fend for themselves. AAEM should fight for fairness for all emergency physicians in all practice settings rather than paint CMGs as EM's bogeyman.
— Robert J. Benkendorf, MD MMM FACEP FAAEM
I agree completely. Like you, I have seen more than one independent, "democratic" group that was anything but democratic and equitable. Many individual contract holders are as bad or worse than corporate staffing companies. Rest assured that AAEM fights for fair and equitable treatment in the workplace for all emergency physicians — whether they are hospital employees, part of an independent local group, or working for a huge staffing corporation. The basic principles of fairness are the same in each situation.
There is, however, one important difference between an independent physician-owned group and a staffing corporation (contract management group or CMG), and it is fundamental to the business model of each. A purely physician-owned group may be fair and democratic — meaning it is owned equitably by its physician members, with each having an equal share of ownership and control, each having full knowledge of the group's revenue and expenses, each having the protection of peer review and due process within the group, and each being free of post-employment restrictive covenants. A CMG not only usually does not provide these things, it cannot provide all these things because it derives its profit - and riches for its principle shareholders and upper management — by taking money away from emergency physicians far in excess of any value it returns to those physicians or their patients. Thus, while it is true that being entirely physician-owned is no guarantee of democracy and fair treatment in an emergency medicine group, it is also true that a CMG that exists to enrich its management and lay shareholders cannot be democratic or treat its emergency physicians fairly.
— The Editor
An Issue that is Not Addressed by Either AAEM or ACEP
Whether you work for a mega group or a democratic group, ED physicians are not afforded the same due process as the rest of the medical staff. It takes a horror story to get a staff physician removed from the medical staff of a hospital. Not so with ED physicians. Without cause, and if the CEO tells the contracting group that he wants Dr. X off the schedule, no reason has to be given. There is no due process. All the CEO has to do is wave the group contract in the groups face and it is all over. The ED doc is off the schedule.
ABEM has been the leader in continuous certification, which although it may be cumbersome at times, it does keep us current with the literature and changes in the practice of EM.
We will never be respected, except perhaps in a hospital with an EM residency, as long as we are not treated as true peers of the rest of the medical staff of the hospital we work at. Please forward to the AAEM president. I lost my job at the end of March. Without being egotistical, I was the best physician in the group, and the highest paid. It turns out hearsay from the nurse manager of the department (too slow?) was enough to get me removed. I was never actually removed from the staff, but I am not permitted to work there.
Until ED physicians are treated with due process, we will never gain the respect for the lifesaving work that we do.
— Evan B. Tow, DO FAAEM
Thank you for writing, and I couldn't agree more. More importantly, AAEM agrees too. Our Academy has been working hard for quite some time to assure due process for emergency physicians, mainly by making it impossible for any physician to be deprived of peer review and due process by an employment contract with a third party such as EmCare, Team Health, or other contract management group. For more on this issue, see the article by Dr. Larry Weiss (attorney and former president of AAEM) in this issue of Common Sense.
— The Editor
Bemoaning the eHarmony Mentality of Job Applicants
We've all seen the ads. You know, the dating site that strives to pair you with the perfect mate based on "29 dimensions of compatibility." It seems like there are a lot of matching services out there and not just for dating. A few clicks and setting of parameters and you can find the perfect hotel, the perfect travel itinerary and the perfect car. Does the same apply to the perfect job?
I've been very fortunate to have the opportunity to lead a group of physicians at a once small, but now much larger, community hospital in Texas. Our group has grown with the hospital and we've even added on a sister hospitalist group to help expand our services and improve patient flow on the inpatient side. Our two groups employ just under 30 full and part-time physicians. But as with most groups in our area we continue to expand and could stand to add a few more docs.
I've placed recruiting ads online with some success but of late have been seeing a somewhat disturbing trend with our applicants. Or maybe I should say with our applicants' spouses. Yes, I said spouses. It first started with our hospitalists when we formed that group about 4 years ago. I interviewed an internist who wanted to bring her husband along. I thought this was a little odd but we were meeting at a restaurant offsite, he was a nice guy, and I recognize that this can be a family decision so why not? And maybe this was one of those "medicine" things we ER doctors don't quite understand. My wife is triple-boarded in internal medicine, pulmonary and critical care so I recognize some quirks exist across specialties.
But then we started getting calls from spouses making initial contact and screening positions based on what they could glean from our practice manager over the phone. And then it happened. The phenomenon crossed over to the ER side. What began as husbands tagging along for lunch, then husbands calling about jobs (and yes, it's almost always the husbands), a wife called about a job for her ER spouse. And she was very aggressive. We provided some basic information and I politely declined to do a phone interview with the wife, offering instead an interview with the candidate himself. Not only did she decline on her husband's behalf, but she wrote a lengthy nastygram to my practice manager saying that unless they knew the "hourly expectations, volume, compensation, benefits and so on" upfront then "we can't know whether it's a good fit for us" and "we can't commit to spending the day on an interview" without this information.
Not once did I ever have any direct contact with the candidate.
Call me old fashioned, and I may very well be, but it seems to me that the natural sequence of events is that you identify a job opening, you make some general inquiries, then you interview for the job and gather the bulk of your information during the interview. Maybe some follow up questions or clarifications thereafter but most of what you would learn about the job would happen onsite where you get an opportunity to see and meet people, tour the facility, watch doctors and staff in action, etc. Try to get a feel for the place firsthand.
Now, I recognize some applicants live a long way away. It's a big state, much less a big country. Many applicants are residents with limited resources. We've all been there. As much as I am not a fan of the telephone interview, we've relaxed our approach a little bit and have been more accommodating. Several of our physicians have volunteered to talk with prospective candidates by phone. We've even utilized newer technologies and have had a few FaceTime chats.
But the candidate I never met and whose wife dismissed us outright, sight unseen? He lives 55 miles away from our hospital. I Googled it. Fifty-five miles! Even with traffic would it be such a burden to come out for a face-to-face?
I regret that there is such a push to extract as much information as possible without an interview and to gauge agreeableness with the "29 dimensions of compatibility" that candidates and employers alike are missing out on opportunity for a meaningful in-person interaction.
-Patrick Woods, MD, MBA, FAAEM
Why Don’t EM Physicians Reproduce
I agree with your statements but would like to add one: The use of patient satisfaction surveys negate the importance of expert emergency care provided by board certified EPs.
If the patient is always right, then you do not need the expertise of a trained EP. If achieving high satisfaction scores by meeting unrealistic preconceived notions propagated by non-physicians and marketing executives has become the current goal in EDs across the country, the EPs will be forced to choose between providing good care and self-preservation.
Under this current system, we don’t need any more experts. Every patient is their own expert. Until we start demanding to be treated like the limited resource that we are, this will not change.
— Dave Bryant, DO FAAEM
Thank you for your letter and I couldn’t agree more. Multiple recent studies have explored the relationship between patient satisfaction and outcomes and I presume that many more studies are underway. I am proud of the family of medicine’s commitment to practice evidence based medicine and willingness to change practice based on that evidence. I am interested to see if administrators will be similarly committed to changing practice based on evidence.
— The Assistant Editor