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Tuesday, August 24, 2021

AHEAD OF PRINT: ​Emergency Medicine’s Past Plagues Its Present

​Emergency Medicine’s Past Plagues Its Present


I had drinks with a legend of emergency medicine in Honolulu in 1994. I met him the evening before when he addressed the Hawaii chapter of the American College of Emergency Physicians. Everyone in the room was blown away by his talk, and I was fortunate to be included at a small dinner with him the following evening.
He regaled us with stories about the old days of emergency medicine in his thick Boston accent. I doubt he remembers that evening, but I will never forget it.

Two years earlier, I was a naïve second-year resident. I was trying to grasp the nature of how to do my job, and it was difficult for me to consider what was going on in the post-residency world of emergency medicine. Our specialty was still young. The majority of EPs were salty veterans of emergency “rooms.”

This group included a lot of physicians who had drifted into the specialty for less than glamorous reasons. Some had been kicked out of residency or had too many malpractice claims. Others had substance abuse issues. Many had little to no formal training in emergency medicine, which had only been recognized as a specialty 12 years earlier. Residency-trained, board-certified emergency physicians were in the minority.

There was a lot of buzz around that time about a book that satirized the business practices of emergency medicine. It was so scandalous the author published under an alias: the Phoenix. That book was The Rape of Emergency Medicine, and the author was James Keaney, MD. Despite the politically incorrect title, it remains essential reading for understanding how emergency medicine became the first medical specialty to be commoditized in the 1980s.

Now and Then
I recently reread the book that made Dr. Keaney famous. It is a hilarious story with a cast of fantastic characters, including scrubs, suits, kitchen schedulers, Crips, Bloods, big cats, mosquitoes, pledge drivers, Weasel, Monk, and Cro-Magnon. The text drips with sarcasm and details the evolution of the emergency medicine business model, an endless turf battle to acquire management contracts for hospital emergency departments while filling shifts with any available clinician. All the while, the contract managers (AKA the suits) developed marketing campaigns that emphasized the quality of their services with slick, glossy handouts and receptions for hospital administrators supplying ample amounts of food, beverages, and gifts.

Shortly after the book's publication, Dr. Keaney was featured in Emergency Medicine News and then part of a feature story on “60 Minutes.” The legendarily tough Mike Wallace interviewed him in a piece that brought to light the staffing models for emergency departments of that era.

The great irony is that 30 years later emergency physicians face a new challenge influenced in part by corporate medicine. Residency-trained, board-certified emergency physicians in the 1980s and 1990s were in short supply, and every business-savvy person knows that scarcity creates value. Entrepreneurs set up corporations that moved around a collection of physicians with varying levels of competence to staff the nation's emergency departments.

These corporations merged and changed into new companies many times over, but a version of that business model continues to be utilized today at many hospitals. The big difference, of course, is now we have more than enough residency-trained, board-certified emergency physicians. The scarcity that created the market in the first place no longer exists.

Historical Reference
With this in mind, how does a company staffing emergency departments continue to prosper when the value of its service goes down? It drops the price to increase sales volume or finds a cheaper way to supply the service. Enter the nonphysician provider.

Of course, the trick now (as it was then) is to convince the consumer (hospital administrators) that your service continues to offer the same (or at least acceptable) level of quality with cheaper labor. You bring in the marketing department to produce more slick advertising that features the quality of your nurse practitioners and physician assistants at a fraction of the cost. (Read "The Corporatization of EM Education" for an example of this strategy: EMN. 2021;43[7]:1;

The net result now (as it was then) is the loss of some of our professional independence. Corporations create standardized processes that can improve quality in the emergency department, but these processes need to balance quality of care with fiscal responsibility. This goal can be extremely tough when other physician specialists providing care at a hospital have the negotiating power to dictate the terms of their compensation because of their professional independence. This dilemma can push hospital administrations to look elsewhere for savings, and that search might end up in the emergency department.

After the publication of his book, Dr. Keaney became a founding member and the first president of the American Academy of Emergency Medicine. This organization has been at the forefront of calling attention to questionable business practices in emergency medicine for nearly three decades. You can download a free copy of Dr. Keaney's book on the AAEM website:

Reading this book provides residents and attendings alike with an essential historical reference for our specialty. It is a call to action for us to advocate for safe clinical environments and fair business practices. I encourage all residents to read his work and think about its impact on their future careers.

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 ( Friend him at, follow him on Twitter @3rdRockUS, and read his past columns at