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The Rise and Fall of Emergency Medicine

Borden, Mark MD

doi: 10.1097/01.EEM.0000791912.92843.b0
    EM history, ED management, EM jobs

    Doctors had few useful treatments centuries ago. They could do a few things, but mostly they understood the path of disease, predicted the outcome of a problem, and invoked friendly spirits, such as leeches, and occasionally an herbal remedy to help those who suffered. A doctor could do little, but he could sometimes say with accuracy, “Get your affairs in order. You won't see next spring.”

    Science began to replace faith in healing. Leeches didn't cost much, local herbs were available, and healing hands had the time to apply their touch and comfort. Science was a bit more expensive.

    Medicine, x-ray machines, and hospitals cost money. Fees went from one chicken to a number of dollars. Drug producers went from a covered wagon selling remedies to huge commercial enterprises with the most powerful political lobby in the world. Teams began to form as a new system arose. Doctors and their nurses (at first subordinates, then a separate but equal team) formed one team, and in the beginning that team, with its training and knowledge of medicine, duty, and commitment to the patient first and promise to adhere to higher ethics, was in charge.

    Lots of time, commitment, and intense study were required to learn (pre-med science, four years of medical school) and to apply (three to eight years of internship and residency) the knowledge of medicine. This did not leave much time to master business. Criteria to measure medical qualifications were clear and used often.

    Now that lots of money was involved, some businessmen began to “help.” Hospitals managed by doctors were at a disadvantage financially because administration and finance also have a skill set. Doctors and nurses outnumbered administrators during this period and were considered valuable. It was clear that doctors should be shielded from the financial machine. Doctors should be free to put their patients ahead of financial motivations. Clearly, doctors should not be employed, and good laws were adopted to prevent doctors from being employed by and therefore subject to the demands of financially motivated administrators.

    Every administrator needed a few secretaries, though, and new departments needed to be created. New administrators were needed to manage these new departments. Soon the administrators and other managerial personnel outnumbered the doctors and nurses (and other medically trained caregivers). Criteria to measure administrative qualifications were vague and not often used. A previous hospital CEO with whom I worked, for example, had no administrative training and no college degree.

    Suddenly, doctors were a nuisance. They remembered the old days when they were considered important and treated with respect, and they acted a little grumpy. Administrators complained that doctors were their problem, and stated that they could better control doctors if they were employees. The employment model was debated and tried. Sure enough, doctors were more receptive to the demands of an administrator if they could be terminated simply by not renewing an annual contract.

    Some doctors objected to being told which surgeries they could perform, how many patients they needed to see each hour to make their quota, and which drugs they could (expensive ones) and could not (less expensive, though often more proven ones) prescribe, but some just enjoyed punching the clock and getting a paycheck without all of that billing hassle and paperwork. Initially, employment was unusual, but it became more and more common until 2019 when more doctors were employed by hospitals than independent for the first time in history.

    Gone are doctors' lounges. The administrators asked, “Why do doctors need to lounge anyway?” Actually, that is where doctors talked, collaborated, and coordinated care of their patients while forming relationships with each other, which led to better patient care.

    Gone are special parking spots for doctors. The administrators asked, “Why do doctors need to park close anyway?” Actually, coming in again and again at night (instead of 9-5) makes having a close spot essential to avoiding traversing a long icy parking lot in the dark.

    Gone is the time required to conduct a thorough history and physical exam. The administrators said, “I like the doctors who just order a CT scan ($2000) instead of wasting time on a physical exam ($69).” Maybe the administrators don't know that the CT delivers the radiation of 500 x-rays, or maybe they just don't know that x-rays are proven to cause cancer.

    The bottom line is that the quality of medical care is suffering as the big dollar business model grows and continues to feed upon itself. Will patients notice? No. Will new doctors notice? Maybe. Most doctors these days clock in and clock out without ever seeing a doctors' lounge.

    Then an administrator had a bright thought: “Why bother employing a doctor when I can get a physician assistant or nurse practitioner for half the price?” It doesn't matter to an administrator that doctors have 10 times the education and training; what matters is the price! With the right incentives, a nonphysician provider can see just as many patients per hour.

    Another bright idea! “Why don't we make our own doctors?” That will help fix this doctor shortage, and we business folks know the law of supply and demand, right?

    What does the future hold? We have lost control of our destiny, and our patients will continue to pay a higher and higher price if we do not regain it. Employees unionize. A union can bargain for better working conditions. When I was in residency, such a thought was beneath my dignity. Now it may be required. Can we enact laws preventing employment of physicians? Must we wait until the government takes action? Remember what I said about the world's most powerful political lobby? No action of significance will come from that sector.

    The only reason I can write this is that I am no longer employed by an administrator-heavy group, and I have 25 years of practice under my stethoscope. Most of our youthful colleagues dare not speak up. The old guard will need to take the lead in the actions that must follow.

    Or we can just retire and be treated for our acute MI by a brand-new, shiny NPP who lives far left on the Dunning-Kruger curve (the all-knowing bliss of near-complete ignorance) while the EP and cardiologist cover multiple hospitals from home.

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    Dr. Bordenis an emergency physician in Washington State and the author of the book Medical Wisdom.

    Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
    • rjybarra510:42:20 AM<span><span>Michaelangelo</span></span> said, “Criticize by creating.”&#160; That was my motto in Texas when I was a revolutionist for independent freestanding emergency rooms and founded the FEC Section with ACEP and the Freestanding Emergency Room Interest Group with AAEM. Larry Weiss, MD, and I wrote the AAEM position statement, and I polished the final version for ACEP. We passed a bill in 2009 with the help of my then-wife as a state representative. In Texas, until recently we’ve thrived, and our association (originally our board was mostly physicians, myself included), supported the FEC entity with physician-oriented “noncorporate principles” (unfortunately that changed as more business people, nonphysician, took over the board). With that said, and all of the truths Dr Borden’s eloquently articulated in a “quick history snapshot,” here’s the new future revealed. Let’s elevate paramedics to a new midlevel status. Let’s utilize them as practice partners and facilitators, and in states that allow, delegate by training and QAPI, skills to enhance our reach by working side by side or remotely with telehealth and other technologies (Google glass, etc). The tagline will be “always be seen by a board certified physician.&quot; (The freestanding emergency center tagline was “own you own ER.”) I believe the world can be better by engaging our natural creative capacities, and mature physicians harness their context and thrive for a noble purpose. Open source “ideas” are gifts to humanity if the intent is clear&#58; healing and caring for ill and injured. Actually, blurring the margins between the specialties, preventing illness and injury could reverse high-cost, unnecessary medical care and the $13 trillion price tag. The value equation is one good thing that “the suits” have given us, quality and cost. Let’s tweak the quality part by keeping our precious training and experience at the service of patient care. There have never been as many tools as we possess now, but we need to use them with compassion and wisdom. Including “creating” new models in the context of our time. Michaelangelo was on to something.
    • Robert McNamara, MD10:21:49 AMLaws already exist in most states to prevent lay corporations from employing physicians. The trouble is leaders of the specialty have aided and abetted these corporations skirting these laws by being the paper owners of sham professional associations that &quot;employ&quot; the physician. Look at this case&#58; A former Texas ACEP president admits to holding 275-300 such entities in 20 states on behalf of Envision&#58; https&#58;// Of course, EM itself and the state medical boards have failed to address this illegal practice because those in power have made millions off of the current state of affairs. As regards to unions, the great barrier is independent contractor status as the dominant scheme under private equity-backed groups. However, as hospitals realize these companies are ruining the ED and begin to employ more physicians (CMGs are losing contracts in a number of systems), the opportunity arises. The American Academy of Emergency Medicine is actively exploring this. I have reservations about unions, but realize the state of affairs makes this attractive to many, and I cannot fault their reasoning. If we do wind up unionized to a large degree, we can look back on all those &quot;leaders&quot; who made their millions, sold out the specialty, refused to address the corporate practices schemes like those above and the fee-splitting issues, and left the current generation holding the bag.
    • glrhame4:29:40 PMBeen advocating this for years. I went into medical training in 1990 when things were great. I got out in 1998 and for the eight years I was in it, attendings were complaining the entire time. I figured it out in 1999. Docs had lost all decision-making and autonomy while I was training. Incomes plummeted. It is hard for younger docs to understand that today, physicians make on average $0.31-<span><span>$0</span></span>.33 for every dollar they made in 1988…33 years ago. This would all stop immediately if those of us with degrees said, “I am going to stay home for two or three weeks.” And, if it didn’t, add another couple weeks to it. All of our power and autonomy, as well as those doctors lounges that I only knew peripherally growing up in Nacogdoches, TX, perhaps would also return as would independent practice.
    • temarnie10:20:32 PMSad and so true!