Here is a question emergency medicine academicians have been asking themselves for years: “What happens when hospital administration comes in and just fires us?” Will the day come when the CEO offloads the cost of running an EM residency by handing over operations to a contract management company? This happens routinely in nonacademic EDs. Large staffing corporations take over and look for ways to make money. They accomplish this by cutting pay, decreasing physician coverage, increasing patient loads, and removing less productive physicians from the staff.
But what if this starts happening in academic EDs? Companies that provide emergency physician staffing would jump at the opportunity. They would get access to a regular stream of graduates that they could subsequently encourage to stay with the company. It would be worth it in recruiting future physician manpower even if the academic ED continued to lose money. Eventually they could probably make the necessary changes to make money. Cutting clinical hours for attendings, hiring more PAs, and establishing tougher performance benchmarks can work in an academic setting as well, can't it?
The timing of recent events seems to be making this dystopia a reality. I wrote in January (“Corporations Rush In to Fill MD Shortage,” EMN 2017;39:1; http://bit.ly/2hXloWW) about how the health care behemoth, Hospital Corporation of America (HCA), was aggressively developing EM residency programs to supplement their current and future physician manpower. Shortly after that column was published, HCA ironically sent an email to all emergency medicine program directors about recruiting faculty for five new EM residency programs opening in Florida. All of this can only be interpreted as corporate EM's push to encroach more and more into the world of academics.
But this pales in comparison with the move made by another contract management group, US Acute Care Solutions (USACS) that has become the biggest news in emergency medicine since it became a specialty. The events at Summa Health in Akron, OH, have gained national attention, and despite the sensational revelations of this story, the eventual fallout is likely just the first of many battles between management and labor in academic emergency departments around the country.
In case you missed it, the small private group that had managed the EM residency at Summa Health for decades was abruptly replaced by USACS. It seems crazy, but literally at midnight this past New Year's Eve, the old academic physicians were walked out the door, and the new ones took over. This occurred despite the fact that most of the new faculty members did not actually live in Akron, and many had marginal experience in academics.
In retrospect, academic EM has seen the writing on the wall for a long time, but was not always willing to accept the possibility this could happen. Large EM staffing corporations have managed an EM residency program in the past, but they are now aggressively starting multiple EM programs from scratch. Still, no one anticipated bearing witness to a group of experienced academic physicians being forced out by a hospital CEO over a contract dispute. Did they really just tell them to leave so they could have a cheaper ED staffing solution? Is it possible that all academic faculty are at risk of finding themselves separated from their residents in a matter of days? Are we at a point where the hospital and corporate health care have all the leverage? The answer would seem to be yes.
Or is it?
The EM World Shifts
Just when it seemed like all hope was lost, the Accreditation Council for Graduate Medical Education (ACGME) decided to visit northern Ohio to see what was going on. My impression is that the business folks running hospitals and multibillion dollar ED staffing corporations thought of ACGME as a toothless group of policy wonks who should be grateful for its very existence. When the ACGME left Akron, however, the EM world shifted just a little bit on its axis.
A small, nongovernmental regulatory agency pushed the health care business folks around that day. They walked in and generated what one can only guess was a very critical report about how EM health care education was being managed at Summa. (I say “guess” because, the report still has not been released by Summa, though the ACGME told Summa they were allowed to do so.) In the aftermath of this ACGME visit, the CEO of Summa Health was removed from his position. To my recollection, this has never happened.
It's not that balancing budgets and making sure hospitals are profitable is bad. But it has to be recognized that education creates value not always apparent on profit-and-loss statements. To think that any group of emergency physicians can walk in the door and instruct residents is a dangerous assumption. Career academicians spend decades honing a variety of skills as varied as public speaking, research, administration, and tactfully reorienting residents who are developing bad habits. To expect a purely clinical emergency physician to be able to recognize how to do this is crazy. It takes years of dedication and experience to learn how to trust young residents and understand what they can do and what they need to do to become proficient.
The ACGME for the time being has given just a little bit of leverage to academic medicine. Maybe this will be enough to influence the financial decision-makers in health care to reorient how they approach education as an imperative investment in the future. Otherwise, the years it takes to develop a team of physicians dedicated to educating their residents might just be forced to leave the building in the middle of the night.