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Friday, January 21, 2022

What EPs Should Know about Oral COVID Drugs

BY LEON GUSSOW, MD

Two new oral medications to treat COVID-19 received Emergency Use Authorization from the U.S. Food & Drug Administration early this year. Emergency physicians and medical toxicologists will soon be dealing with these drugs with which they have little or no experience.

Ritonavir/Nirmatrelvir
The most eagerly anticipated new oral treatment for COVID-19 is Pfizer’s formulation of ritonavir/nirmatrelvir (Paxlovid). The company reported that the drug reduces the risk of hospitalization or death by 89 percent if treatment is started within three days of symptom onset in high-risk outpatients with COVID-19. That sounds great, but keep in mind several important caveats, most importantly that Pfizer has not yet published the results of its clinical trial.

The claim from EPIC-HR (Evaluation of Protease Inhibition for COVID-19 in High-Risk Patients) of 89 percent reduction of hospitalization or death comes from a Pfizer press release describing results from the planned interim analysis of the data. (Nov. 5, 2021; https://bit.ly/3GIr53N.) The FDA issued an Emergency Use Authorization for the drug in December, and the agency apparently reviewed the data and was impressed by the results. Still, I find it somewhat discomforting to base clinical treatment on a press release rather than a real scientific publication.

All subjects in the EPIC-HR trial were high risk and unvaccinated. It is not clear that any potential benefit would be as impressive in other populations. Word has it that an additional study of ritonavir/nirmatrelvir in 662 vaccinated volunteers showed a 70 percent reduction in hospitalizations and deaths over placebo, but these data have also not been published. EPIC-HR also enrolled patients from July 2021 to September 2021 before the Omicron variant was detected and a little before Delta was widespread. Pfizer apparently expects that ritonavir/nirmatrelvir will be effective against Omicron based on laboratory studies and the fact that the drug does not target the virus’s spike protein. Still, it would be nice to have published clinical confirmation.

The SARS-CoV-2 virus when it infects human cells induces synthesis of long protein chains that have to be cleaved at specific points to produce shorter proteins crucial to viral replication. Nirmatrelvir inhibits the main viral protease that enables this precise cleavage. The drug is metabolized by the CYP3A hepatic enzyme system. Ritonavir is another protease inhibitor long used in treating HIV/AIDS, but its role in Paxlovid is to inhibit CYP3A, prolonging the half-life and activity of nirmatrelvir. The combination is given as three tablets twice daily for five days.

Because ritonavir inhibits CYP3A, the potential for numerous significant drug interactions is a real concern. Use of ritonavir could increase concentrations of many other drugs metabolized by CYP3A. Conversely, nirmatrelvir levels may be reduced to subtherapeutic amounts in patients on drugs that induce CYP3A. Clinicians should be aware of these potential drug interactions, and frequently invite input from clinical pharmacists and medical toxicologists when prescribing Paxlovid. (See the table for potential drug interactions in the upcoming March issue.)

Molnupiravir
In contrast to Paxlovid, the initial Merck study on its COVID-19 drug molnupiravir (Lagevrio) has been posted online. (N Engl J Med. 2021 Dec 16; https://bit.ly/3rxwdkS.) This phase 3, double-blind, randomized, placebo-controlled trial evaluated the use of oral molnupiravir to treat nonhospitalized adults with mild to moderate COVID-19. All subjects had PCR-confirmed infection and began treatment within five days of first signs and symptoms.

The subjects were also considered high risk for progression to severe disease based on at least one of the following: BMI over 30, age over 60, diabetes mellitus, active cancer, chronic kidney disease, chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, and cardiomyopathy. Exclusion criteria included ongoing hemodialysis, renal failure with a GFR less than 30, pregnancy, and previous vaccination for COVID-19. That last point is important: All the subjects in this study were unvaccinated. They received molnupiravir 800 mg bid for five days or placebo. The primary endpoints were hospitalization or death within 29 days of treatment initiation.

A total of 1433 subjects were randomized into the study, and a planned interim analysis was carried out after the first 775 patients were enrolled. The results initially looked promising. The interim analysis found that 7.3 percent of the group receiving molnupiravir reached a primary endpoint compared with 14.1 percent of the placebo group, a relative reduction of about 50 percent.

The final results from all 1433 study subjects were not as striking, with 9.7 percent of the placebo group reaching a primary endpoint v. 6.8 percent of the treated group, a relative reduction of 30 percent. It is not quite clear why these results were less positive than those from the interim analysis. The study took place from May 2021 to October 2021, so it is possible that few if any subjects from the interim analysis were infected with Delta variant, and that molnupiravir may be much less effective against the variants common now.

Notably, one death occurred in the treated subjects and nine in the placebo group during the 29 days after treatment was started. Adverse effects not directly related to COVID were generally nonspecific and included diarrhea, nausea, and dizziness.

It is important to realize that this trial was carried out among nonvaccinated subjects infected with mostly the Delta, Mu, and Gamma variants. Randomization also ended in early October 2021 before the Omicron variant was a concern. The results gave no indication of how effective the drug would be today, with new variants, or in vaccinated patients.

Monupiravir works by inducing multiple mutations as viral mRNA is copied in infected cells. There has been concern that this mechanism might accelerate development of more virulent or infectious mutations, but so far experience with the drug—although still quite limited—has not detected examples of this occurring.

Molnupiravir has been shown to induce mutations to mammalian DNA in cultures of hamster ovary cells (J Infect Dis. 2021:224[3]:415; https://bit.ly/3IbuAQA), but no data yet suggest this would be a problem with therapeutic use. In any event, the drug is not recommended for pregnant patients or those who might become pregnant during treatment.

Dr. Gussow is a voluntary attending physician at the John H. Stroger Hospital of Cook County in Chicago, an assistant professor of emergency medicine at Rush Medical College, a consultant to the Illinois Poison Center, and a lecturer in emergency medicine at the University of Illinois Medical Center in Chicago. Follow him on Twitter @poisonreview, and read his past columns at http://bit.ly/EMN-ToxRounds.

Monday, January 3, 2022

Starting a Ketamine Clinic: Another Option for EPs

BY SAMUEL KO, MD, MBA

I have been working as an emergency physician for the past decade, but I took a leap four years ago into the world of side gigs by starting a ketamine infusion clinic in Palm Springs, CA.

The seed was planted years ago when I came across an early article about the off-label use of ketamine for depression. (Biol Psychiatry. 2000;47[4]:351.) I was curious and did a deep dive into the research and stayed on top of the latest studies and meta-analyses, which showed continued support for its efficacy in treatment-resistant depression. (J Affect Disord. 2020;277:831.)

I never imagined I would own my own clinic. Surprisingly, it’s one of the best decisions I have made in my career. I was able to transition out of night shifts and holidays. I now decide what time to start and end my clinic hours. Most importantly, my patients get rapid improvement compared with traditional antidepressants that can take months to take effect.

About Depression
Ketamine was invented in 1962 by Calvin Stevens, PhD, while consulting for Parke-Davis Research Laboratory. It was approved by the FDA in 1970 as a dissociative anesthetic agent, and is on the World Health Organization's list of essential medications.

Ketamine is used in the ED for procedural sedation, acute pain control, severe agitation, delayed sequence intubation, and even as a third-line agent for status epilepticus.

Interestingly, research is showing that sub-dissociative ketamine doses infused over 40 minutes can be effective for treatment-resistant depression. Improvement can last days to weeks after one infusion, but benefits seem to accumulate with multiple infusions (typically six infusions over two to three weeks).

It’s not ideal to give multiple treatments for depression in a busy ED, but that can be done in an outpatient clinic. Ketamine infusions are also not routinely covered by insurance, and out-of-pocket-costs can be significant for many patients. Janssen Pharmaceuticals, which is owned by Johnson & Johnson, released intranasal esketamine, which was approved by the FDA in 2019 for depression, and it is reimbursed by insurance companies.

A recently published systematic review and meta-analysis showed that intravenous racemic ketamine is more effective than esketamine for depression. (J Affect Disord. 2021;278:542.) Insurance companies will likely realize that it will save them money in the long run to cover IV ketamine treatments.

Current State of EM
Emergency physicians have always been on the cutting edge of medicine. We are trained in administering ketamine as well as vital sign monitoring and addressing potential side effects. We are also adept at handling any potential acute airway and cardiovascular issues as well as psychiatric emergencies.

I believe ketamine clinics can be an opportunity for emergency physicians who are curious about starting a side gig while taking more control over their future. By collaborating with psychiatrists and other mental health professionals, EPs are uniquely positioned to meet the increased demand from patients suffering from depression. That could also be a solution to the projection that emergency medicine will have an oversupply of 8000 physicians by 2030 (Ann Emerg Med. 2021;78[6]:726; https://bit.ly/3lVrGYu) and concerns about graduating residents being unable to find jobs because of COVID-19. (AAMC. Feb. 25, 2021; https://bit.ly/2P2M3Vz.)

The Downside
Starting a ketamine clinic has challenges. One of the benefits of emergency medicine is being able to clock in and out for shifts and be done. Owning your own medical practice will mean thinking about it all the time. This option is not for those who don’t want to devote extra time to their clinic.

You’ll likely also be criticized by your colleagues who may say that you are profiteering on the backs of suffering patients and peddling snake oil and that you are not a psychiatrist and only they should provide ketamine infusions. They may even accuse you of getting patients addicted to ketamine. And much more.

This venture is definitely not for you if you haven’t yet developed a thick skin in medicine. You’ll also have to get involved in the business aspects of medicine, such as marketing, accounting, and hiring. Some of this can be outsourced, but you’ll need to be willing to learn the basics.

Initial Steps
But a ketamine clinic just might be for you if you are entrepreneurial, proactive, and looking for a change. The first few steps will involve writing a business plan, finding a location, getting business licenses and malpractice insurance, and ordering medications and supplies. It took me about two years before physically opening to learn the nuts and bolts of starting a ketamine clinic. It then took two years after opening to establish a patient base. I continued working part time in the ED while the patient volumes grew at the clinic to keep my finances stable.

None of us is taught how to open up a private practice in medical school or residency, so I had to do a ton of research to launch the clinic. I made a free checklist you can download at www.ketaminestartup.com to get things started if you’re interested.

Dr. Ko is the CEO of a ketamine clinic (www.resetketamine.com) and a creator of an online course on how to start a ketamine clinic. (www.ketaminestartup.com.) Follow him on Twitter @drsamko.

Tuesday, November 16, 2021

​A Smackdown for Epinephrine Skin Necrosis

BY BLAKE BRIGGS, MD

My aversion to medical myths started long before residency. I distinctly recall as a third-year medical student on my EM rotation when an attending showed me how to perform a digital block but instructed me to avoid using lidocaine with epinephrine due to the “theoretical” risk of digital necrosis. When I asked what “theoretical” meant, he replied, “It has probably never happened, but I would hate to be the first!”

The dogmatic belief that 1:100,000 epinephrine causes necrosis to distal appendages on the human body has unfortunately been drilled into practicing physicians and young, impressionable students for decades. The thought is that locally injected epinephrine will cause necrosis of the toes, fingers, ears, and even nose due to sudden vasoconstriction, leading to local ischemia.

Why do we care? Subcutaneously injected epinephrine has notable benefits. It has been shown to increase lidocaine’s duration of action in local injection, especially digital nerve blocks. (J Hand Surg Am. 2014;39[4]:744; Plast Reconstr Surg. 2006;118[2]:429.) It also reduces bleeding at wound sites, making it especially useful in highly vascularized areas (e.g., scalp lacerations).

A comprehensive literature review reported that only 21 case reports between 1889 and 1949 described finger necrosis when epinephrine was used. The concentration of epinephrine was not known in 17 of the cases. (J Emerg Med. 2015;49[5]:799.)

It is incredible how pervasive myths can be. The digital necrosis myth is particularly interesting because literally no cases have been reported since 1949. This was the same year the Soviet Union detonated its first atomic bomb, West and East Germany were established as separate countries, and electron microscopy was developed. But many students and young physicians are still taught this dogmatic fear in 2021.

Follow the Data
Today epinephrine formulations currently available include 1:100,000 and 1:200,000. A few physiologic studies have been performed, and normal perfusion was present after an hour, though perfusion might have decreased for 10-60 minutes in the affected digit. No decrease in local capillary pH or blood gas was seen. (J Hand Surg Eur. 2008;33[4]:515.)

Seven retrospective studies (ranging from 43 to 200,000 patients per study) and two prospective studies (23 and 1340 cases in each) demonstrated no cases of digital necrosis in the fingers, toes, and feet. (J Emerg Med. 2015;49[5]:799.)

Let’s assume the worst. What if a patient had a high concentration of epinephrine injected into the digit? Thankfully, data are available on this too. Fitzcharles, et al., in 2007 reviewed 59 cases of EpiPen autoinjector discharge with a 1:1000 concentration injection into the finger. These cases were unintentional, usually sustained by a child or loved one playing with another person’s EpiPen. More than half of the cases did not receive any locally injected phentolamine (the preferred reversal agent) yet suffered no ischemia. (Hand [NY]. 2007;2[1]:5; https://bit.ly/3Fhaunz.)

Another review of 365 epinephrine autoinjector injections to the hand were reviewed in 2010, finding that no patients suffered permanent damage. Four patients suffered “ischemia” and received phentolamine treatment, but we are unsure how the reports defined ischemia given that no permanent damage occurred. (Ann Emerg Med. 2010;56[3]:270.)

Perhaps most damning to this dogmatic belief is whether a dilute, subcutaneous injection of epinephrine really causes harm given the lack of evidence that highly concentrated epinephrine (1:1000) causes digital necrosis. It simply curtails the myth even more if a patient can safely be exposed to 100 times the dose of epinephrine that we would normally use in a standard digital nerve block or local anesthetization.

This is not much of a clinical controversy but more a clinical dogma smackdown. Decrease your patient’s pain and improve the visualization in your field by using subcutaneous epinephrine mixed with lidocaine. If a student asks you about the “theoretical” risk of necrosis, you should reply that it certainly was theoretical … in 1949.

Special thanks to one of our readers, Tom Benzoni, DO, for suggesting I write about this topic.

Dr. Briggs is an assistant professor of emergency medicine at the University of South Alabama in Mobile. He is the founder, podcast co-host, and editor-in-chief of EM Board Bombs (https://www.emboardbombs.com), a multiplatform educational tool designed to provide board prep and focus on what you need to know for the practice of emergency medicine. Follow him on Twitter @blakebriggsmd.

Tuesday, November 9, 2021

​Is Emergency Medicine Ready to Unionize?

BY RUTH SORELLE, MPH

Answerable to corporate profits, subject to firing without due process, lacking transparency in billing, and beset by increasing work hours and dwindling pay, emergency physicians are increasingly considering whether unions and collective bargaining could hold promise for them.

They would like, at the very least, to wrest control of their practices from corporations and private equity. But unions will not unilaterally change the problems of corporate health care, said Stuart Bussey, MD, JD, the president of the California-based Union of American Physicians and Dentists. (https://www.uapd.com/.) “Physicians are commodities,” he said. “Medicine is on sale. It has always been that way. No one is pushing back.”

Joe Crane, the national organizing director of the Doctors Council, the nation’s oldest and largest union of physicians (https://doctorscouncil.org), said at the virtual TakeEMBack Summit in September, that unionizing is a step in the right direction, but physicians must determine whether unionization is possible, first asking why they want to unionize. “We cannot legally organize just the emergency department group,” said Mr. Crane. “We have to look at every physician employed at your facility. Do the issues that impact you impact other physicians? How is the company formatted and who reports to whom?”

He said 30 percent of the doctors should sign on to wanting a union to start the legal process of triggering a vote to unionize. That petition is turned into the National Labor Relations Board, which triggers an election. “We need the votes of 50 percent plus one to organize,” he continued. “At that point, we are looking at around 70 to 75 percent of the workforce, an overwhelming majority, so we can go in with a mandate. While that is going on, the employer cannot make unilateral changes in workforce policies.”

During negotiations over safety and working conditions, physicians should not be afraid to speak up. Federal law ensures the right to organize, and an employer cannot retaliate because of those efforts. Mr. Crane estimated that it could take 18 months to two years to get a first union contract. “[S]tart fighting now,” he said. “I honestly am not sure where things are or how things are going to get worse, but they will. We have organized a smaller hospital that was part of a bigger system, but it took almost three years to get that first contract. Every step along the way, the company’s response was, ‘This is going to impact all the other physicians in our system.’”

Overcoming Obstacles
Emergency physicians face an unusual problem because many of them are independent contractors who cannot form unions under current laws. The stock answer for people who are independent contractors and file a 1099 with the IRS is that they cannot unionize because they are not employees, Mr. Crane said, but he added, “If you are a W-2 employee and you have someone you report to who can get you fired, you most likely have the right to unionize. The bigger question is going to be, ‘Are you actually appropriately classified as 1099?’”

Dr. Bussey said a law could be passed allowing physicians to bargain collectively, though that method has been tried and failed in Congress. “We have the power of strike,” he said. “We don’t use it. We have the power of picketing, and we do use it. The employer does not like the spotlight put on their bad practices. After we picketed, they settled the contract.”
Dr. Bussey said he understood and empathized with physicians who are afraid. “They keep ratcheting down their money and increasing their hours,” he said. “Like the frog in boiling water, you better jump while you can. Nurses are getting higher pay. Physician assistants and nurse practitioners are getting more money. Doctors have to do something because their industry is being whittled away.”

The American Medical Association’s 2020 biennial analysis of physician practice arrangements show that most American physicians work outside of practices. (American Medical Association. May 5, 2021; https://bit.ly/3iI9DTk.) More than 50 percent of emergency physicians are estimated to be employed by contract management groups, and a recent workforce study by the American College of Emergency Physicians predicted an oversupply of emergency physicians by 2030. (Ann Emerg Med. 2021;S0196; https://bit.ly/3lVrGYu.)

Striking Out
The need for unions became clearer during the pandemic when institutions were reluctant to provide the resources and staffing needed to care for patients, said Brian Fox, DO, a family physician who practiced at Indigo Urgent Care in Washington State. “It is an excellent time to unionize right now,” he said. “A little of the pressure is off. We could not think about organizing in the middle of the pandemic.

“We found that the state of Washington had a stockpile of N95s,” he continued. “The organization we were working with didn’t request them from the state. They did not want to present a scary image to people who walked in. This is not acceptable. You are playing with provider and patient lives for optics. The bottom line is we are labor, not professionals, now.”
Striking initially seemed like an anathema to physicians, but they found that they could do it surgically. They first picketed to lay their concerns out in the open, and then they struck for two days. “Eventually, there was a little movement on some issues, but a lot of providers got so fed up they left,” Dr. Fox added. “The new providers did not know what the issues were. The eventual contract was slightly better than the employment contract we had individually.”

Robert McNamara, MD, a past president of the American Academy of Emergency Medicine, said it is a suitable time for emergency physicians to work collaboratively to improve their working conditions. It might be questionable to consider emergency physicians contractors because they have little say in their schedules, must give 90 days’ notice before leaving a position, and can be fired without due process.

A Rock and a Hard Place
Dr. McNamara said his major concern is the corporate practice of medicine, which can find emergency physicians under the thumbs of contract management groups and the private equity firms that own them. He said current issues in the job market, including the pending oversupply of emergency physicians, is making the prospect of unions acceptable. AAEM has a policy that supports members who unionize but advises EPs to seek practice ownership through existing regulations that prohibit fee-splitting and the corporate practice of medicine. (May 16, 2004; https://bit.ly/3iIwLAX.) ACEP’s policy does not mention the term union and says EPs may participate in collective bargaining units, and mentions four times that they must ensure the timely provision of emergency care. (October 2020; https://bit.ly/3mAxfdu.)

“There is no reason a small group of emergency physicians working for one of the corporate entities couldn’t organize in just one or two emergency departments in a system. That would be possible and a good test,” Dr. McNamara said. “It could spread like wildfire if it happens.” He said he hoped ACEP would recognize the need to start fighting the corporate practice of medicine.

The group TakeEMBack may provide an outlet for collaboration for those who are concerned about their lack of independence and protection as physicians. (https://www.takemedicineback.org.) The future could be complicated, however, as insurers begin to acquire contract management firms. The $2.2 billion acquisition of Sound Inpatient Physicians Holdings by OptumHealth (owned by the UnitedHealth Group, a health care and insurance company) and the investment firm Summit Partners raises the specter of physician contracts being acquired by health insurers. (Fierce Healthcare. June 7, 2018; https://bit.ly/3mvddRD.)

“We’re between the proverbial rock and the hard place,” said Dr. McNamara. “My personal belief is that aligning with private equity to fight insurers [who want to acquire groups] has diminished the specialty in the eyes of the public and legislators. It was an unholy alliance, and we pay the price for that.”

Ms. SoRelle has been a medical and science writer for more than 40 years, previously at the University of Texas MD Anderson Cancer Center, The Houston Chronicle, and Baylor College of Medicine. She has received more than 60 awards, including the Texas Human Rights Foundation Award. She has been a contributor to EMN for more than 20 years.


Tuesday, November 2, 2021

​Few Feasible Solutions to EM’s Workforce Crisis

BY THOMAS P. COOK, MD

The American College of Emergency Physicians published a highly anticipated report on the future of the emergency medicine workforce this year that concluded that our current trajectory will yield nearly 10,000 too many emergency physicians by 2030. (Ann Emerg Med. 2021;S0196; https://bit.ly/3lVrGYu.)

What we can do about this? The ACEP task force that conducted the study provided a list of possible solutions. (“Workforce Considerations: ACEP’s Commitment to You and Emergency Medicine,” ACEP Now. April 21, 2021.) Let’s take a look at them.

Raise the bar to ensure consistency across emergency medicine residency training, and stop the proliferation of emergency medicine residents and residency programs.
These two items suggest that regulatory control of emergency medicine training programs will slow the production of emergency physicians. The only organization that holds all residency programs accountable, however, is the Accreditation Council for Graduate Medical Education. The ACGME will not limit the number of programs that can acquire accreditation, citing concerns about the legal ramifications of restricting trade.

Can the ACGME raise the bar by requiring all programs provide residents with adequate exposure to clinical experiences achieved at institutions with Level I trauma, STEMI, and stroke centers? Possibly, but this would likely cause headaches for a substantial percentage of EM programs. Raising the bar would become an unpopular political quagmire.

The ACEP workforce report also suggested that EM residencies could voluntarily extend training from three years to four or decrease the number of residents per class. The idea that more than 275 programs would all agree to chew their foot off simultaneously is never going to happen. Increasing the length of EM residency training exploits young professionals already up to their eyeballs in debt by taking away one year of their opportunity to pay it off. This type of solution only kicks the can down the road. These residents eventually graduate and become part of the oversupply problem. (EM Physician Workforce of the Future webinar. April 9, 2020; https://bit.ly/2Ra6sbQ.)

Expand the reach of emergency medicine to ensure that no community is left behind, and support practicing physicians to encourage rewarding practice in all communities.
These items appear to be an effort to push back against the many small, rural emergency departments primarily staffed by nonphysician providers (NPPs). Unlike the other suggestions by the task force, this is a realistic short-term opportunity to increase the number of jobs for EPs. EPs in rural areas tend to be older and not trained in emergency medicine. As they inevitably retire, it creates a void that can be filled by new EM graduates to provide high-quality emergency care that was not ubiquitously present in the past. The question remains if corporate health care will upgrade physician staffing in these rural locations or use less expensive NPPs. Is it realistic to think that EPs will want to work in rural areas? The evidence says no, but circumstances may force them to, as I noted earlier this year. (EMN. 2021;43[5]:17; https://bit.ly/3gMDDNE.) The question remains whether corporate health care will use residency-trained EPs to upgrade physician staffing in rural locations or use less expensive NPPs.

Ensure the appropriate use of nurse practitioners and physician assistants to protect the unique role of emergency physicians.
The ACEP report projected that more than 38,000 NPPs will deliver care in our nation’s emergency departments by 2030. Forces pushing the expanded use of NPPs include an increasing number of for-profit schools, strategic lobbying efforts, and the quiet support from corporate health care to use more NPPs as a way to cut costs and boost profits.

Physician advocacy to challenge this is commendable and worth pursuing. Still, this message is hard to sell when pitted against nursing organizations marketing “increased access to care” as a reason to expand their ability to practice independently. The public finds this tactic alluring, and nurses are considered the most trusted profession in the United States year after year. (Oakland University. Jan. 22, 2021; https://bit.ly/3uQJfvi.) Naturally, politicians are reluctant to work against them, and EPs are currently losing this battle state by state.

Broaden the umbrella to expand emergency physician scope of practice.
This has been in place since the dawn of the specialty. EM spread into a number of clinical areas over the past three decades, such as airway management, critical care, ultrasound, thrombolytics, trauma, stroke management, tactical EMS, aeromedical EMS, and event medicine. Nonetheless, the problem with the strategy of expanding our scope of practice is whether we can create enough jobs to support 10,000 surplus EPs. It does not seem likely at this time.

Ensure business interests are not superseding the needs of educating the workforce, and set the standards for emergency medicine so every patient has access to a board-certified emergency physician.
Kirk Jensen, MD, an emergency physician and the former chief innovation officer for the contract management group Envision, recommended methods for maximizing efficiency and reducing costs for emergency care by using fewer emergency physicians and more non-EM-trained physicians (FM and IM) while letting NPPs care for more than 30 percent of the less acutely ill patients. (EMN. 2021;43[9]:1; https://bit.ly/3oJF3fV.)

Many emergency physicians consider Dr. Jensen and others like him as unsupportive of the cause we fought for over the past half century. EDs, however, are often financial sinkholes. Hospital administrators will look to folks like Dr. Jensen to improve their bottom line regardless of how many residency-trained EPs cannot find work. After all, hospital management might care a lot about the quality of their health care, but they usually care more about the fiscal health of their organization.

Where does this leave us? Unfortunately, emergency physicians may be at the mercy of financial markets. Health care gobbles up 17 percent of our gross domestic product. (Centers for Medicare & Medicaid, National Health Expenditure Data. Dec. 16, 2020; https://go.cms.gov/2TlqgH0.) Americans want the best service and quality but not the price tag that goes with it. The high cost of emergency care is frequently vilified in the media, and we may be in for a rough ride. Markets are like sharks. They do not have feelings. They do not understand your personal or political bias. They only seek efficiency, no matter the cost to us.

Dr. Cook is the program director of the emergency medicine residency at Prisma Health 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 at http://bit.ly/EMN-Match.