I am hanging up my stethoscope and exiting the ambulance bay doors for the last time after 10 years as a residency-trained, board-certified emergency physician. I chose emergency medicine to care for critically ill and injured patients, and I'm leaving because this has become nearly impossible.
I believe it is imperative to share some of the reasons that I and many like me are leaving a field we once loved. Their ramifications will affect you and those you love sooner or later.
I arrive for each shift as an emergency physician, but most of my shift is spent as a podiatrist, dentist, pediatrician, urgent care provider, nursing home doctor, mental health counselor, primary care doctor, and social worker. Employing my emergency medicine skills on those rare occasions when they are needed is challenged by the strained and overextended ED staff and resources.
Emergent patients may wait 45 to 90 minutes before they are triaged and their wildly abnormal vital signs recognized due to the three families who arrived just before them for well-check visits, school notes, and sniffles. These nonemergent patients are increasingly being courted and catered to by the corporations that own and run emergency departments. After all, you cannot increase the number of emergencies to increase emergency department profitability, but you can increase the number of nonemergent visits.
This has progressed at some hospitals to the point where these customers (I hesitate to call them patients) are being actively targeted by advertisements informing them that school and camp physicals, previously the domain of the family pediatrician, can be expeditiously performed at their local ED 24/7 without any forethought or scheduling required. They are also informed that they can make ED appointments online to avoid waiting when they arrive, an idea as fatuous as it sounds.
Apologists within my profession encourage us to embrace the new normal and appreciate the increased job security these nonemergent visits provide. This is as absurd as encouraging our nation's fighter pilots to crop dust and tow advertising banners for job security in between missions, neglecting the harmful impact this would undoubtedly have on their primary and essential role.
Doctors' Tip Jar
The effort to attract nonemergent wallets to the ED and maximize Medicare reimbursement comes with a tremendous emphasis on tracking and aggressively enforcing patient satisfaction. The surveys utilized to determine patient satisfaction (such as ED CAHPS) are administered only to patients who are discharged from the emergency department, large swathes of whom, almost by definition, do not have emergent conditions.
This hyperfocus on patient satisfaction is actually harmful. Studies suggest improved patient satisfaction scores correlate with higher costs and mortality rates. This makes sense when you consider whether linking high school teachers' pay to their students' rating of them would produce improved or impaired educational outcomes. Good clinical practice and what the patient truly needs often conflict with what the patient wants or expects.
This places physicians between a rock and a hard place. Leaving the patient unsatisfied (although appropriately treated) inevitably results in hearing about it from some higher-up scanning the Google reviews and feedback forms. Physician salaries are tied to patient satisfaction and quality clinical practice measures (e.g., MIPS) in some cases.
Physicians faced with an irate patient demanding antibiotics for his viral infection or a head CT after a minor head bump can in effect choose to sacrifice their satisfaction-linked salary by denying inappropriate care or their quality metrics-linked salary by administering it. Faced with these incentives, most of us eventually give in to some degree to inappropriate patient demands to avoid the scolding emails and the unspoken deleterious effect they may have on our careers.
There is a reason medical organizations have long decried patient gifts as an ethical landmine while most every other industry has pushed tipping to unimagined levels of intrusiveness. We are medical professionals, not a customer service industry. This is especially true in the emergency department. If you are uncomfortable with the idea of your doctor carrying a tip jar, you should likewise be uncomfortable with the idea of his salary being tied to patient satisfaction.
The corporations now running much of the medical infrastructure have injected their love affair with metrics into emergency medicine. The bureaucrats who developed these metrics, most with no experience in medicine, have little concern with the actual outcomes resulting from this obsession. Administrators have regular meetings to discuss and track these metrics, some of which I have had the misfortune of attending. Backs are slapped and bonuses distributed when the numbers improve, but we see a different story on the ground.
High-Fives in the C-Suite
Disposition time and time-to-room are metrics fanatically tracked at hospitals. Maximum targets for disposition time are allotted to each level of acuity assigned at triage. More acute patients (ESI 3) must be dispositioned within, say, three hours and less acute (ESI 4) ones within 100 minutes. Some hospitals have solved the problem of chronically underperforming on this metric by simply increasing the acuity levels assigned at triage. It's not unusual to see a level 2 ankle sprain at these facilities. Rather than actually addressing the reason taking an x-ray and giving ibuprofen take longer than it should (typically understaffing and crowding), the metrics are buffed and high-fives exchanged in the C-suite.
Time-to-room metrics have been subpar because EDs don't have enough nurses and many admitted patients are boarding in the ED, meaning the majority of patients are seen in the waiting room where they are packed in like sardines. Even admitted patients often spend hours sitting in the waiting room. Some hospitals have addressed this not by hiring more nurses but by creating a new virtual “room” in the computer system and “placing” all lobby patients there. The patients camped out in the lobby would be surprised to hear it, but these patients have now been roomed as far as the spreadsheets are concerned. More bonuses and backslapping for the bureaucrats.
Meanwhile, the administrators blame us and admonish us not to violate HIPAA in the lobby while knowing full well that we don't have the rooms or time to pull each patient back into privacy for every update. This is particularly true given the number of patients who, immediately upon arrival and regardless of their presenting complaint, demand a wheelchair and then almost miraculously lose the power of locomotion. But that's irrelevant; their goal of absolving themselves of any liability is accomplished, while they rely on our commitment to the Hippocratic oath and professionalism to shoulder the increased risk and continue doing our best to serve our patients.
The number of emergency medicine residencies grew from 160 in 2013 to 273 in 2022, and predictions are that there will be a glut of emergency physicians by 2030. Many, if not most, of these new residencies are not affiliated with universities and provide a substandard education. They have been started by corporate hospitals eager to access GME funds ($150,000-250,000 per resident per year), tap a source of cheap labor (residents), and ultimately flood their local markets with physicians, driving down their greatest cost, salaries.
Those of us trained prior to the explosive growth of these programs talk among ourselves in disbelief at the poor training provided and the inadequacy of their graduates, but flooding the market has also translated into far less career security and kneecapping physicians' ability to protest any of these travesties. We have seen it time and again: The squeaky wheel is simply removed.
When a hospital informs the EM group that they will be starting a residency, they comply or are replaced. This results in attending physicians who intentionally chose nonacademic jobs and are unwilling, unskilled, or unable to teach being tasked with training the next generation. In short, the quality of education and medical care is being sacrificed at the altar of corporate profit.
No Quality Control
Emergency departments are increasingly being staffed by nonphysician providers—physician assistants (PA) and nurse practitioners (NP). They are a cost-effective alternative to residency-trained physicians. I am fortunate to work with many skilled PAs and NPs, but I have also worked with those atrociously ill-equipped to see patients in the ED or anywhere else. Many NPs undergo two years of online training immediately after graduating from nursing school, and there is little to no quality control or standardization of that education.
Referrals to the ED by NPs (whom patients often think are physicians) frequently reflect a dangerous lack of medical knowledge. Given the increasing workload and demands placed on emergency physicians, they are also often inadequately supervised. Physicians are forced to sign their charts, typically without having seen the patient. Bylaws may require the supervising physician to see every patient, but again this is merely administration protecting itself from liability while knowing full well that the demands of the job rarely make this possible. My family members and friends all know to insist on being seen by a physician. Unfortunately, many of my patients are not as well informed or lucky enough to have that option.
Emergency departments have limited staff and resources, and these are being misallocated at dangerous levels. You or a loved one will experience a life-threatening emergency at some point. Would you choose an emergency department where patients with hangnails and stubbed toes rate doctors highly for the amount of time and attention lavished upon them or would you rather pick an emergency department where these non-emergencies are expeditiously dispositioned and the bulk of time and resources are allocated to those with true emergencies? Would you rather your family member be cared for by a well-trained and properly educated emergency physician or a nonphysician practitioner who completed a two-year online course?
I certainly know my answers to these questions. I can no longer be a part of the travesty that emergency medicine has become, and that is why I am leaving.
The author is an emergency physician practicing in the western United States.