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Breaking News: Academic EM and Contract Management Lock Horns

SoRelle, Ruth MPH

doi: 10.1097/01.EEM.0000407844.78478.1f
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For nearly 30 years, emergency physician Howard Roemer, MD, took care of all comers to the emergency department at St. Francis Hospital in Tulsa, OK, and for the past five, he trained emergency medicine residents from the University of Oklahoma, Tulsa, School of Community Medicine. A clinician and teacher who loved his role as healer and educator and currently the president of the Oklahoma Chapter of the American College of Emergency Physicians, he recently received the James Keaney Leadership Award from the American Academy of Emergency Physicians, of which he is a member. To most people, he would seem the consummate role model in the profession.

He worked his last rotation at St. Francis in August, however, his job a victim to a clash between the needs of academic medicine and the demands of Emergency Medicine Physicians, Ltd., the Ohio-based emergency medicine staffing and management group that holds the staffing contract for the emergency department at the hospital. Dr. Roemer is loath to say that the demands of academic medicine clash with those of contract groups, but he admitted, “In this particular instance, it didn't mix. There were too many variables on each side that prevented it from working out.”

Dr. Roemer's own emergency medicine group, ECI, staffed the St. Francis emergency department for several years until the hospital requested proposals from other groups. He said his group's request to renegotiate the contract likely contributed to the hospital's move. Emergency Medicine Physicians (EMP) in Ohio won the contract. “The way it worked was that EMP would not contract with the university for the doctors' clinical hours directly,” said Dr. Roemer. “For us to work in that department and train the residents, we had to become employees of EMP. We also had academic contracts with the university.”

That worked for a couple of years, but then the University of Oklahoma changed its policies. The doctors had to be paid through the university. “That was one of the things that led to a big problem with the relationship with EMP,” said Dr. Roemer.

In July 2010, the OU department of emergency medicine worked out a contract with another Tulsa hospital, Hillcrest Medical Center, a 691-bed facility. “The main elements were financial assistance and significant operational control over the department,” said Dr. Roemer. “EMP was not willing to do that at St. Francis, and St. Francis was not willing to give money to the [OU] emergency medicine department. That led us to move our base hospital to Hillcrest. A significant chunk of resident rotations went to Hillcrest, but we wanted to keep a presence at St. Francis, the main trauma center in the region. The majority of faculty moved to Hillcrest.”

EMP would not negotiate an arrangement that would allow the full-time University of Oklahoma doctors to be paid through the university, even though there was no difference in the money outlay, Dr. Roemer said. Finally, there were just two academic physicians left at St. Francis.

Then, one day, Dr. Roemer said he was driving to a departmental meeting at OU when he received a call from the president of EMP in Ohio. The president told him that because the group's relationship with the university had changed, they were invoking the 90-day notice clause, Dr. Roemer said.

“I was kind of shocked,” he said. “I asked if there was any other way to continue working there.”

He was told the goal was to have full-time physicians at the hospital to maintain continuity of care. When he offered to be available when the group needed him if they would allow him to maintain privileges at the hospital, they refused that as well. He said the other physician's contract was terminated as well.

“It was almost a punitive decision,” said Dr. Roemer. “There is no residency program there now.”

EMP declined to comment on the situation. Its chief executive officer Dominic J. Bagnoli, MD, wrote in an email: “Unfortunately, this is an issue between us and the physicians involved, and we do not comment on such issues.”

Howard Blumstein, MD, the president of AAEM, said, however, that the academy is concerned that faculty members are facing a conflict of interest. “How can a faculty member who is employed by a contract group express his or her feelings about the desirability of working for one of these groups without facing job action? Is he or she free to give advice to residents? I believe not,” he said. “Likewise, how often are the contract groups looking at the residents as a source of cheap labor rather than as trainees who need to be taught? Your emphasis will be different, depending on how you view them. If the company is looking at residents as a source of supplemental labor, does the residents' education suffer? Should the residents be told the situation they are getting into? AAEM has a lot of reservations about that.”

Similar concerns were raised in an emailed statement from Stephen Thomas, MD, MPH, a professor and the chair of emergency medicine at the University of Oklahoma Tulsa School of Community Medicine. “During my 2009 recruitment to join the building of a Department of Emergency Medicine at the University of Oklahoma, much attention and thought were devoted to the issue of base hospital ED leadership,” he wrote. “Given the circumstances in Tulsa, I judged that OU's goal of building a world-class EM program was highly unlikely to be achieved with the extant Saint Francis Hospital (SFH) arrangement, in which the OU EM chairman lacked the authority and responsibility as chairman at the hospital ED. To the credit of my hiring dean, I was encouraged to — and did — convey this opinion to SFH, well before I ever moved to Oklahoma. To the credit of SFH, that institution's leadership collegially discussed their decision to continue their contract for ED coverage with a national contract group.

Dr. Thomas noted that SFH acted well within its rights to determine ED staffing at its hospital, just as OU acted within its rights to choose the training locations best for its residents. “My program director and I judged that our residents' overall educational goals and objectives would best be assured by their working their ED shifts at the new OU base hospital for EM, Hillcrest Medical Center (HMC). This decision was not made lightly,” he wrote.

Dr. Thomas said OU wanted residents to work in an ED where all attending physicians were OU emergency medicine faculty, and where they could interact with medical students and have access to and control of peer review cases involving OU faculty and residents. “At HMC, where the OU Department of EM chairman is also the ED's chief of service, the conditions for residency training were judged by me to be sufficiently preferable to warrant a move of the residents,” he wrote. “Two EM faculty, who had been with OU's Department of EM since its founding, were for various reasons supposed to remain at SFH for part or all of their clinical work. These two faculty were both terminated by the contract group staffing SFH. Since there was no communication between OU and the contract group regarding their change in employment status, I cannot provide details as to why they were terminated.”

Dr. Thomas said he recognized the contract group's right to decide that the physicians should be released, as he said he was sure EMP respected his right to determine that “top-quality EM training is not likely to occur in a situation in which a university EM program's base ED is administered by an out-of-state business venture.”

Dr. Roemer continues his employment with the university and continues to teach but not in a clinical setting. He is an associate professor and the medical informatics director of his department.

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In Brief

New Results from SAMMPRIS

When Marc Chimowitz, MB, ChB, of the department of neurosciences at the Medical University of South Carolina, and his team began their NIH Stenting vs. Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) study in October 2008, they hypothesized that the addition of an intracranial stenting system would decrease the risk of stroke or death by 35 percent over two years compared with intensive medical therapy alone. What they found contradicted that, however, forcing an end to new enrollment in April.

Instead, 14.7 percent of patients in the stenting group experienced a stroke or died within the first 30 days of enrollment, compared with 5.8 percent of patients treated with medical therapy alone. That result remained consistent over the less– than-a-year follow-up period.

New results from the study now show that patients at high risk for a second stroke who received intensive medical treatment had fewer strokes and deaths than patients who received a brain stent in addition to the medical treatment. (New Engl J Med 2011;365[11]:993.)

“The SAMMPRIS study results have immediate implications for clinical practice,” said Dr. Chimowitz. “Stroke patients with recent symptoms and intracranial arterial blockage of 70 percent or greater should be treated with aggressive medical therapy alone that follows the regimen used in this trial as closely as possible.”

The intensive medical management includes a daily dosage of 325 mg of aspirin and 75 mg a day of clopidogrel for 90 days after enrollment as well as aggressive management of key stroke risk factors such as high blood pressure and high levels of low-density lipoprotein, the unhealthy form of cholesterol.

The researchers said the results may have come from half of the patients receiving a self-expanding stent. The study participants were in the highest risk category with blockage or narrowing of 70 to 99 percent of arteries. Patients were between 30 and 80, had experienced a recent transient ischemic attack, or another type of non-disabling stroke.

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