Here's a first-job story you probably haven't heard before: A senior EM resident decides that he and two of his physician friends will convince a local hospital to give them the EM contract and create their own jobs.
The protagonist of that story is my boss Dominic Bagnoli, MD, and that's how he co-founded Emergency Medicine Physicians in 1992. It's a great story, and it's unfathomable that it could happen today. The health care industry has simply changed too much, and so has emergency medicine.
I will under no circumstances advise you in 2018 to attempt creating your own medical group straight out of residency. There probably isn't a hospital or health system in the country today that would give its contract to an inexperienced ED startup group.
Back then, however, it was possible. Tailwinds were at health care's back. ED volume was on a seemingly never-ending upward trend. Reimbursement had fewer hoops to jump through. Documentation requirements were a fraction of what they are today. And comparative patient satisfaction scores didn't even exist. I even recall hearing in 2003 about an emergency physician leader yelling at a patient that he was in his ED, and if the patient didn't like it, he could get (expletive) out. Imagine if that happened today.
The Nonemergent Problem
It's not just emergency medicine that's changing; it's the entire spectrum of medicine. You would have to be living under a rock to have missed some of the industry-shaking news from the past few months. CVS announced it would buy Aetna, UnitedHealth said it would buy DaVita Medical Group, Advocate Health Care and Aurora Health Care plan to merge, and so do Catholic Health Initiatives and Dignity Health.
These deals and the dozens of mergers and acquisitions over the past few years are and will continue to have a profound impact on health care in America. I believe that they will have a profound effect on your career as well.
You have likely heard that all parties in health care, from national, physician-owned groups and the health systems with which we partner to the government and private payers, are all being pushed to provide more efficient and better care at reduced cost. A big part of that means guiding the nonemergent cases out of the ED and lowering location and provider costs.
I've repeatedly heard physicians complain that 70 to 80 percent of patients who present to the ED don't have an actual emergency. Well, guess what? Our flawed and sometimes messy system is conspiring to fix that nonemergent problem one way or another. I believe that although emergency departments collectively will see lower total volume, you and I (as residency-trained, board-certified emergency physicians) will see an increasing percentage of patients with high-acuity presentations. We are a specialty perfectly trained to handle those, and we are going to get our chance to prove it.
The best things you can do are to build your skills, keep seeing the sickest of the sick, and embrace the acuity, high or low. You likely will never create a brand new group right out of residency with a handful of your classmates or colleagues, but the upside of today's shifting market is that you are going to get to do more of what you are trained for—care for the patients who need you most.
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