From the Editor’s Desk: We Need to Take Care of Our Children

Andy Mayer, MD FAAEM

The statement above was made at a recent AAEM Board of Directors meeting. It may sound like a strange statement to be made at such a meeting but it carries great significance. Most physicians believe that there is a duty for each physician to encourage, mentor, educate, protect, and to take care of the next generation of physicians. Our profession is both an art and a science and we learned our skills from physicians who came before us and we owe a debt to those who will follow us. Emergency physicians need to look at the looming workforce issue with an eye towards protecting our patients and the young, dedicated, idealistic physicians who are looking to emergency medicine as a career. Choosing a specialty in which there is a rising certainty that new emergency medicine residency graduates will be unable to be empowered to advocate for their patients or have any control over their careers is disturbing at best and disastrous at worst. The health and safety of both these young physicians and the patients who they will care for in the coming years is at stake.

There were lengthy discussions during this meeting related to the looming workforce issue which emergency medicine is facing. The projected surplus of graduating emergency physicians in the coming decade is something which cannot be ignored and certainly the time for action is now. The consequences of the projected glut on the house of emergency medicine is now the big hot topic. The roles of private equity and corporate management groups in this coming crisis are actively being discussed in many forums. The time for endless discussion and study is past and now is the time to do something to prevent a catastrophe for a generation of young intelligent physicians who will be entering a supersaturated job market with few reasonable options. These physicians will typically be shouldering a huge student loan debt at a time when most plan to be starting families and settling down into a long and fruitful career. What will be their reality and what viable options for a successful career will be available to them?

Each emergency medicine organization looks at this issue from its own perspective and often with their own best interest in mind. The house of emergency medicine needs to put aside any self-interest or self-protective instincts and do what is right for our patients and our profession. The specialty has to come together and work in unison on this issue. Concerns about membership numbers and advertisement income need to be put aside. Letting private equity inflate a labor pool for shareholder’s profit at the expense of patient safety is such a strange and absurd concept to me that it is hard to believe our healthcare system could be so broken as to permit this onerous outcome.

Let’s just consider if a glut of thousands of unemployable or under employable residency trained emergency physicians is good for our patients? One might think that oversupply would lead to lower costs for the patient and therefore could be considered a good thing. I suspect few of you believe that any money saved, any significant salary reductions will be passed on to the patient. Do you think that the private equity and corporate management groups which are leading the push to produce this glut are doing this for the good of the American people? They want cheap labor who they can hire to work for a lower salary and at the same time require them to supervise more non-physician providers. These physicians will have to accept any job which they can get often with virtually no power to advocate for the health and safety of the patients. These young emergency physicians will be left alone in the middle of the night to treat and care for the sick while the corporate management group executives and the owners of private equity firms are sleeping soundly in their beds. Will these physicians be willing to speak out when they have a patient care or safety concerns related to staffing, boarding, or the increasing requirement for them to sign non-physician provider charts? I suspect these vulnerable physicians will feel compelled to remain silent to protect their fragile job security. They will not feel that they can afford to risk their job as they will know there will be another wave each year of new graduates competing for their job who will work for less and under worse conditions.

AAEM is trying to take action and stop talking. We are encouraging other emergency medicine organizations to do the same. Dr. Mark Reiter, a past president of AAEM has done significant work on this issue and made a proposal to the board which was accepted as the policy statement below.

Raising Emergency Medicine Residency Standards

Introduction

AAEM has received much feedback from our members regarding concerns that the rapid proliferation in the number of emergency medicine resident positions, and increased utilization of non-physician practitioners at emergency department training sites has negatively impacted the quality of emergency medicine resident education.

Position Statement

AAEM suggests the ACGME Emergency Medicine Residency Review Committee take action to raise emergency medicine training and quality standards by setting a minimum number of patients at the primary site emergency department per resident and setting a maximum percentage of emergency department patients seen by non-physician practitioners (NPPs). Specifically, AAEM advocates for the implementation of a standard of one resident per 3,600 patient volume at the primary residency training site and a maximum of 25% of patients seen by NPPs. Residency programs will be able to devote more resources to each resident and faculty/resident ratios would improve. Emergency medicine residents would benefit from exposure to more emergency patients, resuscitations, and procedures, and would have increased faculty access and supervision. Expected shortages in other medical specialties can be addressed by reallocating excess emergency medicine resident positions.

Earlier this year the RSA and AAEM sent a letter to Douglas McGee, DO who is the Chair of the ACGME Review Committee. The letter asks the ACGME to look into the rapid expansion of residency programs in for-profit hospitals where the staff are employed by for-profit staffing companies. The letter also expressed the concern that emergency medicine residents were simply being used as “cheap labor” by these for-profit entities with links to private equity. AAEM and the RSA asked for an investigation into this issue. A copy of the letter is below.

Dr. McGee responded in a letter which essentially cites a 1984 policy in which the ACGME claims that it can only accredit residencies and that it has no power to limit any program who meets the minimum standards for institutional and program requirements. It essentially claims that they have no ability or responsibility in regards to the future emergency medicine workforce. To be fair, when these policies were made no one would have thought that any for-profit entity would come to control emergency medicine programs or find a profit motive for the training of residents so they could cheaply staff their for-profit emergency departments. Most reasonable people would determine that the ACGME does now have a duty to change their policy and ensure that the training of emergency medicine residents is done in an ethical and prudent manner for the protection of our patients and the healthcare system. A copy of his letter back to AAEM and the RSA is below.

Attn: Felicia Davis, MHA

Executive Director RC for Emergency Medicine ACGME

Suite 2000

401 North Michigan Ave

Chicago, IL 60611

Dear Ms. Davis and ACGME Emergency Medicine Review Committee,

Due to the proliferation of emergency medicine programs, I am concerned regarding the standards of resident education. Emergency medicine residents benefit from exposure to more emergency patients, resuscitations, and procedures, and should have increased faculty access and supervision. For this reason, I would support the implementation of a standard of one resident per 3,600 patient volume at the primary residency training site. Also, more and more non-physician practitioners (NPPs) are staffing emergency departments and their presence may hinder the access to procedures and training opportunity for residents. I would also implore the Review Committee to institute a limit on the number of NPPs staffing emergency medicine training sites. Thank you for considering these very important issues and for your commitment to emergency medicine resident education.

Sincerely, Andrew Mayer, MD

What can be done? First, we must try and strongly encourage the ACGME to reconsider and revise their 1984 policy position on accrediting new residency programs. Second, we need to educate and convince the ACGME that many of the new residency programs which they have accredited are actually not providing adequate training. It is hard for a reasonable person to believe that many of these new small to medium residency programs at smaller community settings could possibly provide an adequate number of patient contacts or procedures for each resident. Simulation is great but actual real world procedural and patient care experience is needed to protect our patients. I ask each of you to send a letter to the ACGME today. Dr. Vicki Norton has done great work on AAEM’s advocacy page and I hope you will explore the site and become involved in more than this one issue. All you need to do is go to AAEM Advocacy page and click on the TAKE ACTION NOW tab on the top right. Then click ACTIVE CAMPAIGNS and finally RAISING EM RESIDENCY STANDARDS. A letter will be generated for you like the one below which I sent. It is very easy and quick and please also take a look at the other campaigns which AAEM is working on.

The last action which I want to ask for you to consider doing is the hard one. Dr. McGee in his letter to AAEM and the RSA proposes an idea. On page two of his letter he suggests that individuals provide specific complaints and concerns to the ACGME. He asks for specific concerns “regarding the educational environment in a program, including the balance of education and service.” He states that such claims will be taken seriously and that they will be “diligently” addressed. He asks for “explicit comments detailing the incidents which led to these concerns.” Are you a current resident, graduate or attending of such a program? Do you have legitimate concerns about the adequacy of the training at such a program and be willing to stand up for the future of our specialty and the future safety of our patients? I strongly encourage you to consider taking action. Remember that we do need to take care of our children!