Seventy-seven emergency medicine residency programs received their initial accreditation by the Accreditation Council for Graduate Medical Education since 2016, and the overall number of positions increased by 37 percent, which begs the question, Is the profession being glutted?
The American Academy for Emergency Medicine thinks so; it released a statement earlier this year expressing concern that current trends may produce more emergency physicians than are needed. (AAEM Position Statement, Spring 2019; http://bit.ly/2EQPDd9.)
Some of that increase can be attributed to osteopathic programs previously accredited by the American Osteopathic Association changing over to the ACGME. But even if we take that into account, the number of new programs opening their doors still substantially outpaced the previous three decades.
The AAEM statement also expressed concern that “the vast majority of new emergency medicine residencies are sponsored by national contract management groups or by national hospital networks that may have a vested interest in creating an oversupply of emergency physicians.”
Are large contract groups such as US Acute Care Solutions and TeamHealth and large health care organizations such as HCA responsible for a significant component of the surge in emergency medicine training opportunities?
US Acute Care Solutions is a contract management group that staffs more than 220 emergency departments; it was launched in 2015 in partnership with Welsh, Carson, Anderson & Stowe, a private equity firm, according to its website. (http://bit.ly/2TVqDrl.) Various sources say the company has more than 1000 employees and an annual revenue of more than $500 million, but USACS did not respond to EMN's request for confirmation. The company's website says, however, that their physicians manage eight EM residency programs in seven states, three of which started after 2015.
TeamHealth, a subsidiary of the Blackstone Group, also a private equity firm, is a much larger organization with more than 18,000 physicians, physician assistants, nurse practitioners, and nurses in 3,400 civilian and military hospitals, clinics, and physician groups in 47 states, according to their 2015 filing to the Securities and Exchange Commission. That filing also reported nearly $83 million in net earnings on $3.6 billion in revenue in 2015. (http://bit.ly/2HkzIVL.)
The company generated some controversy in 2003 when the company staffed the new EM program in Tampa, and they are currently involved with several other EM programs. It has also diversified beyond emergency medicine into a variety of other specialties. TeamHealth does not list the EM programs they staff online.
HCA has a gross annual revenue of $46.7 billion and 262,000 employees, according to its 2018 annual report (http://bit.ly/2YZuEkm). It entered the EM residency business in 2016. At that time, I reported in this column my conversation with a member of the HCA recruiting staff about their intent to train and retain emergency physicians. (EMN. 2017;39:1; http://bit.ly/2ZhrF6k.) They opened 11 residencies between 2016 and 2018, eight in Florida and one each in California, Nevada, and South Carolina. (HCA; http://bit.ly/2MqGKwl.) Each program has at least 12 residents per class, a total of 135. HCA is responsible for nearly 20 percent of the 667 new residency positions created in the United States since 2016. This is from a company that had no experience in managing an emergency medicine residency five years before.
It is also interesting to note how the traditional providers of residency training, the university-affiliated medical centers, appear to be less inclined to develop new programs. Only 19 of the 77 new EM programs since 2016 have an affiliation with a university medical school. Around 60 percent of the programs that started before 2016 have a university affiliation.
What should we make of this? Providing training to attract skilled employees is nothing new for any business, whether it is plumbers and electricians or nurses and doctors. My training occurred at a small community hospital where we were the only residents. The goal of my employer (the United States Army) was to have as many EPs as possible because we are the most suited for battlefield medical care.
The company I work for now is a relatively small contract management group that covers five hospitals in a small city. It goes without saying that when we identify a talented resident and have an open position, we speak with him about sticking around the mothership (and many of them do). My point is that everyone does this, so what's the beef?
If only it were that simple. When massive companies apply their vast resources to a problem (in this case, getting enough emergency physicians to staff their EDs), it generates a lot of disruption, causing unintended consequences. The corporations want a stable workforce, and even though building an emergency medicine program from scratch is expensive, it is much more cost-effective in the long run. But this is done to the detriment of new residency grads taking on huge loan debt. How will it feel for them to pay back $250,000 while huge, highly profitable health care organizations increase their bottom line by slowly nibbling away at their paycheck?
This dilemma will not go away anytime soon. Cash-strapped public universities and profit-driven private medical schools are not going to decrease tuition. They will keep pushing the price up until they bleed all the money they can from a student's wallet.
Will corporate medicine pay off their loans without an equally effective financial incentive for them? Perhaps the future of medical school education will be to apply to a large health care company immediately after college to receive medical school tuition in exchange for multiple years of service at reduced pay. Many nontraditional formats for financing a career in medicine may be forthcoming, and the implications of corporate medicine flexing its muscles in the realm of residency training will have a huge impact.
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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 (http://emergencyultrasound.com). Friend him at www.facebook.com/3rdRockUltrasound, follow him on Twitter@3rdRockUS, and read his past columns athttp://bit.ly/EMN-Match.