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Emergency Medicine Needs a New Deal Too

Pena, Robert C.F. MD

doi: 10.1097/01.EEM.0000758768.61113.8a
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    debt, jobs
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    President Joe Biden showed enormous bravado in handling the pandemic during his first 100 days in office. His unapologetic determination to loosen the rusted wheels of American politics has Washington barreling like a train toward the light at the end of the COVID tunnel.

    Three million vaccinations are being administered every day, well ahead of schedule, while recent passage of the $1.9 trillion American Rescue Plan Act of 2021, also called the COVID-19 stimulus package, has become one of the largest relief bills in history. Following close on its heels, plans for a mammoth-sized infrastructure bill to the tune of another $2 trillion have already been announced. Those who say President Biden is the spitting image of FDR and his New Deal might be on to something.

    Yet for all this progress, several issues have doused the hopes of medical students and residents alike, particularly in emergency medicine. Senators Chuck Schumer (D-NY) and Elizabeth Warren (D-MA) called on the president in February to forgive $50,000 in federal loans per student, essentially eliminating all debt for 80 percent of borrowers (CNBC. Feb. 17, 2021; https://cnb.cx/3n7AWqX) and reducing the median $200,000 owed by graduating medical students. (AAMC. Oct. 14, 2020; https://bit.ly/3nb2HPC.)

    This would address the enormous debt students incur while attending college and medical school, which has surged eight times the rate of wage growth since the 1990s. (SoFi Learn. April 9, 2020; https://bit.ly/3tB0vmS.) But President Biden seems reluctant to wield this authority.

    Supporters argue that the Higher Education Act allows this, yet he insisted on investigating the breadth of his loan-erasing powers through the Justice Department. Until then, students and residents must settle for his suspension of federal loan interest accrual and payments through September, an initiative that originated under President Trump.

    Current emergency medicine residents and fellows have been hit even harder. Despite serving in the deepest trenches against COVID-19, facing more than 31 million cases and more than 560,000 deaths so far, graduating physicians-in-training have found themselves in a professional twilight zone. (CDC COVID Data Tracker; https://bit.ly/2QCBFnW.) EDs and ICUs have been flooded with COVID patients, but overall visits plummeted 42 percent early in the pandemic. (MMWR Morb Mortal Wkly Rep. 2020;69[23];699; https://bit.ly/3v5sHi1.)

    This dealt a blow to programs' abilities to train their cohorts through exposure to bread-and-butter cases (STEMIs, appendicitis, nosebleeds). This can be ameliorated somewhat through simulated learning and perusing Tintinalli, but the sudden vanishing of employment opportunities cannot.

    Physician hiring requests have plunged 30 percent this year alone. (AAMC. Feb. 25, 2021; https://bit.ly/2P2M3Vz.) The American College of Emergency Physicians also recently completed a two-year study revealing a surplus of 9000 emergency physicians by 2030. (ACEP EM Physician Workforce of the Future; https://bit.ly/3egXrWl.) At the same time, EDs have attempted to stem the $50 billion hemorrhage from last year and the $122 billion blow expected this year (American Hospital Association. Feb. 24, 2021; https://bit.ly/3aqjrNx), despite mass vaccination and increasing patient caseloads.

    Federal assistance has been provided, but Janis Orlowski, MD, the chief health care officer for the American Association of Medical Colleges, said she believes it is “nowhere near to covering the losses.” (AAMC. Feb 25, 2021; https://bit.ly/2P2M3Vz.) Instead, institutions compounded the economic strife of their emergency staff, cutting work hours across 83 percent of hospitals surveyed. (ACEP EM Physician Workforce of the Future; https://bit.ly/3egXrWl.)

    More so, the wounds of COVID-embattled physicians have been further salted by the 10.2 percent cut in the new Physician Fee Schedule for 2021. (ACEP. https://bit.ly/3ecViuW.) ACEP has successfully convinced Congress to freeze certain cuts and raise code valuations, but a two percent decrease remains, with the moratorium set to expire in 2024.

    Democrats' newfound power must be wielded to help emergency physicians and students. For the newest cohort of physicians-to-be, costs from undergraduate and medical school tuition, USMLE exams, and the residency-matching process must be curtailed. This means expanding reduced tuition programs offered through public institutions, better loan and scholarship access for medical school-bound students, and more income-based tuition forgiveness programs like the New York Excelsior Scholarship.

    This transfers the financial onus from students to taxpayers who need well-trained providers, mirroring the tax-based support of other public programs. Precedence for Congressional oversight for private institutions can be found under the Civil Rights Act of 1964 (Titles VI and VII) and the Education Amendments Act of 1972 (Title IX). There is simply no excuse for not passing legislation that protects students and new doctors.

    President Biden must aggressively push for expanded protections and benefits for residents and fellows as he has in other sectors. Physicians are vulnerable during training; they are nascent members of America's workforce who receive minimal compensation for disproportionately large duty-hour and debt obligations. Their $65,000 salary, which has barely outpaced inflation by one to one-and-a-half percent, puts residents at the mercy of ever-increasing living costs while spending thousands of dollars on Step 3, in-service, and board exams. (Medscape Residents Salary & Debt Report 2020. Aug. 7, 2020; https://wb.md/3sANSXF.)

    President Biden needs only to follow another revered Democratic president for guidance. President Lyndon Johnson signed the Social Security Act Amendments of 1965, establishing Medicare with funding for residency education. Now called graduate medical education payments, these salaries are calculated according to hospitals' costs in training residents and fellows using convoluted formulas and data from 1984 adjusted for inflation and location.

    But only the fraction applicable to Medicare patients is federally reimbursed. The rest is up to hospitals, and therein lies the rub. (Committee on the Governance and Financing of Graduate Medical Education. Sept. 30, 2014; https://bit.ly/3dyGzLJ.) Resident salaries should not be determined by 37-year-old data nor based on one demographic. Why should an EM resident's salary depend on dialysis prevalence? Why should pediatric emergency medicine fellows' salaries be set by those criteria when they never deal with patients over 65?

    The solution is simple. We need legislation that protects hiring for emergency physicians based on non-pandemic volume and that creates separate funding for training-physician compensation. We could easily combine the 75 million Medicaid and 62 million Medicare enrollees from 2020 (minus 12 million dual enrollees) and double the patient volume incorporated into resident reimbursement. (Centers for Medicare & Medicaid Services. November 2020; https://bit.ly/3enKMBk; CMS. February 2021; https://go.cms.gov/3v2wqNe; The Medicare Resource Center. June 10, 2020; https://bit.ly/3gqAkva.)

    Residents simply cannot be faulted for employment in hospitals with low Medicare volume after an algorithm over which they have minimal control placed them there. Nor can they be expected to work 60 hours weekly, fight COVID-19, and lose valuable training with no guaranteed hiring afterward, all for $22 an hour.

    President Biden has an enormous task before him. He must heal a country battered by party politics and a pandemic. Yet as he strives to “build back better,” following the leads of FDR's New Deal and LBJ's Great Society, he cannot leave our emergency medicine residents and students behind. We are citizens too. We have dreams for this country. We want to work. All we need from you, Mr. President, is our own new New Deal.

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    Dr. Penais an emergency medicine resident at George Washington University.

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