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After the Match: Big Brother and EM Fellowships

Cook, Thomas MD; Gerard, Bill MD

doi: 10.1097/01.EEM.0000443914.30982.b5
After the Match

Dr. Cookis the program director of the emergency medicine residency at Palmetto Health Richland in Columbia, SC. He is also the founder of 3rd Rock Ultrasound (;;and @3rdRockUS). Dr. Gerard, right, is the chairman of emergency medicine and the program director for the EMS Fellowship at Palmetto Health Richland.







The National Collegiate Athletic Association (NCAA) is routinely called to account for its policies on payments to athletes by universities and third-party payers. Many feel the purity of college athletics can be maintained only by limiting what all college athletes receive in compensation, but the policy spills over to where an adult cannot control the legal rights to a basic source of self-identity: his own signature.

If a college sports superstar (say, a freshman Heisman Trophy winner) receives a few thousand dollars for inking his name, the sports talk radio world blows up, and the NCAA swoops in with investigators. This happens in spite of the fact that the top 10 college football programs brought in profits of more than $500 million in 2012 (gross revenue well over $1 billion). My home team, the University of South Carolina, came in 17th at a paltry $26 million of profit on $48 million of revenue. (Forbes;

What does this have to do with fellowship training in emergency medicine subspecialties such as EMS and ultrasound? Simply put, the ACGME and hospital offices of Graduate Medical Educationare overreaching to control post-graduate education, and are strangling our ability to advance the specialty. Let me explain.

ACGME has a labyrinth of rules and regulations. It takes program directors years to decipher the cryptic code of what a program must or should do to keep it in line with expectations for training competent and compassionate physicians. The ACGME mission, however, should be only to guarantee quality training and prevent mistreatment of post-graduate trainees.

Interestingly enough, the ACGME does not dictate how much a resident should make nor the source of the money. Unfortunately, as with all government and pseudo-government organizations (ACGME is not a government organization; it just feels like one), paranoia takes over at hospitals that train residents. To comply with every rule, hospital GME offices overreach on how to deal with compensation for ACGME-accredited fellowships.

A shining example of this is EMS. Last year EMS became an ACGME-accredited subspecialty, and programs around the country that had operated outside the realm of ACGME now had to play by a new set of rules. The swagger of ACGME accreditation was realized for EMS graduates, but a lot of programs got more than they bargained for. Funding for programs dropped, and several of these fellowship programs did not fill. How did this happen?

Program directors in the past could compete for fellows by offering compensation more in line with market principles. You could pay your fellow with dollars that came from a variety of sources. Most programs simply had their fellow work as an attending in their emergency department and be paid an hourly wage like any other attending. Salaries could be up to $100,000, and their work also generated money to pay the fellowship director to run the program.

But with ACGME accreditation, hospital GME offices now feel obligated to compensate these fellows based on the pay scale for their post-graduate year. That means an EMS fellow will be paid as a PGY 4 or 5 (around $50,000 per year) rather than what the market can offer. So you're thinking, “Big deal. Just let the fellow moonlight to make up the difference.” Well, it's not that easy.

The Department of Health and Human Services, primarily Medicare, pays for the majority of post-graduate medical training. It is this tax-based financing that covers resident and fellowship salaries for most ACGME-accredited positions. When a resident treats a Medicare patient without an attending physician evaluating that patient, however, the federal governmentviews this as double-dipping because the resident is paid by the feds and now forks over more money for an attending evaluation that did not occur. This seems reasonable, but the intent of this rule is corrupted when applied to fellows in ACGME-accredited, federally funded subspecialties.

Here's an example. Your EMS fellow is internally moonlighting as an attending in your ED. The income he generates is used not only to pay his salary, but also to pay for the fellowship director's protected time to run the program. The fellow takes a call over the radio during his shift from an EMS unit bringing a Medicare patient to the emergency department, and the fellow then treats the patient in the ED. Some hospital GME offices view this as double-dipping because the fellow's EMS training is funded by the feds. Never mindthat all EPs answer EMS calls as part of their regular duties in the ED.

This overreaching concept could be applied in other circumstances. Let's look at emergency ultrasound fellowships. Currently, emergency ultrasound is not ACGME-accredited (but is on the pathto becoming one), and most ultrasound fellows work in the program's ED to generate annual salaries between $80,000 and $100,000. With ACGME accreditation, however, many will view it as double-dipping if the ultrasound fellow performs an ultrasound on a Medicare patient while working as an ED attending. The fact that emergency ultrasound skills are required for ACGME-accredited EM residency graduates isn't taken into account. The fellow must have an attending present to sign off on his chart, but this cancels his ability to generate money to support himself and pay the fellowship director.

I know, I know. You are thinking we should just not fund this fellow's training with federal dollars so he can do whatever he wants to earn income while in fellowship training. Once again, it's not that easy. Most hospital GME offices think that all ACGME-accredited residents and fellows must be treated the same, and that means he has to be paid like all the others.

Hospital GME offices also must cut another resident or fellow position to support the new fellow's training or eat the cost because federal funding for post-graduate training positions has been capped for more than a decade.The profit margin for hospitals with training programs is typically very thin, and the money required each year to pay the fellow and the fellowship director is often not a viable option. Your non-ACGME program that is now ACGME-accredited cannot be funded, and it's “bye-bye” fellowship.

Believe it or not, all of this may not be the biggest hurdle to get emergency medicine residency graduates to go into fellowships. The real obstacle is money. No other specialty with a three-year training program provides as much annual income upon graduation as emergency medicine. Average salaries for emergency physicians are more than $300,000, and trying to get a 28-year-old emergency medicine grad to go into fellowship training at $50,000 per year is not easy, especially when he is carrying more than $200,000 in student loan debt. We are graduating more and more EPs each year, but the demand for their services continues to be extremely high, and salaries will continue to rise. But fellowship graduates are needed to provide the infrastructure for the growth and development of all specialties, so what's the solution to support this in emergency medicine?

There is no silver bullet, but coaxing a young emergency medicine graduate to go into fellowship training requires more money than the median American salary (currently $52,000 per year). Most grads are well into adulthood and up to their eyeballs in debt. As a program director, I have often seen senior residents who just want to pay off their ballooning credit card liabilities. The ability to make even $100,000 is often enough for them not to panic and to explore fellowship training.

Like the NCAA, ACGME and hospital GME offices need to relax a bit and not split hairs over every issue that could in some bizarre way be considered an infraction of the rules. Doctors, like elite athletes, just want a little respect while they working their butts off to get better. In the big scheme of the gigantic cost of health care to the U.S. government, allowing fellowship programs to self-fund by allowing fellows to moonlight internally is an incredibly small amount of money, and the benefits of increasing the collective knowledge of medical science is certainly worth it. If the feds are not going to increase funding for residency and fellowships positions, they at least need to be more tolerant of innovative strategies to help training hospitals pay for them.

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