I read Dr. Edwin Leap's column, and he really hit the nail on the head with many of his comments. (“More and More Doctors, More and More Miserable,” EMN 2008;30:14.) Thanks for creating a forum where some of these issues may be brought to light and discussed.
I am a 30-something EP practicing for five years in California. I also spent a couple of years on the East Coast. It really is a jungle out there in the ED “pits” from coast to coast. The lack of control most doctors experience is definitely adding fuel to the general burnout. I personally make every attempt to limit and eliminate debt when possible, which gives me a degree of autonomy in my practice. I do not need to work an obscene number of shifts just to keep up. There is also mental freedom knowing I am not in jeopardy of losing my income and home from an unpleasant interaction, whether it is with a patient, hospital administrator, ED staff member, or fellow physician. If things ever get rough, there is security in knowing I have many options, including taking some time off.
As a result, I find myself within a minority of emergency physicians who do not wish to bury their heads in the sand and simply collect a paycheck. I find myself one of the few voices present and willing to speak up at monthly meetings, even when there are grumblings in the pit all month long. I believe in the idea of right and wrong, and in not simply looking the other way when one is in the midst of wrongdoing, even when it is too complicated to pinpoint precisely. When physicians are scared to ask about money billed in their names and not allowed to collectively control practice details, that just seems wrong to me. It also seems wrong when we physicians are more concerned about keeping up with the Joneses than we are about the details of our practice sites.
I strongly believe physicians have an obligation to make choices carefully. Even our personal life choices can have an impact on the overall health care system. For example, when we acquire massive debt, we are no longer free to express important opinions, which may be distasteful to certain interested parties. We are all well aware that certain powerful individuals can immediately reduce our workload without reason, consequently controlling our income. As inconvenient as our opinions may be, they are important and should not be silenced, which is something we do to ourselves and our colleagues when we have massive monthly overheads and/or work for the highest bidder without regard to company structure and process.
We all know the decades of sacrifice and delayed gratification it takes to become an EP. It's only natural to enjoy the income we experience after completing residency. Many of us have families to support, or simply wish to play after many years of sacrifice. The more money we make, the more fun we can have playing, and we can buy better toys as well. I only wish some of us didn't go so crazy with the extra zeroes we start seeing on our paychecks after residency.
When I see a friend or colleague add a high six- or seven-figure home to a six-figure education debt, I immediately know that he will never be able to stand up for himself or anybody else for that matter. Debt is the new shackle. There are some great doctors out there supporting groups that should not occupy such an important place in our specialty nor wield so much control over our lives and livelihoods. I hope we will shift our mind-set regarding contract holders. They never call themselves employers for legal and business/financial reasons, and we should never consider them employers.
Most, including site directors, are middlemen and provide a service to the hospital and to the emergency physicians. They are paid well to provide these services. Once physicians start looking at them as service providers, we will feel less intimidated and expect good service for the fees we pay. We do, after all, pay fees for these services, but of course, this is counterintuitive considering who cuts the checks and has executive decision-making authority. This is the same reason we have almost no control over the amount we pay in fees or the process by which decisions are made. Once we collectively stop considering ourselves dispensable, we may begin expecting more respect and control in our practices. EPs may be a dime a dozen, but there are plenty of hospitals in need of good emergency physicians, so we can be picky. Most of us work at two and three places. We do not need to feel intimidated at any one place, especially if we are under more than one umbrella group.
An even more “out there” and radical idea: What stops a group of 10 doctors from getting together and bidding for one of these ED contracts up for grabs, and then outsourcing the accounting and billing services that are too tedious and complicated to handle? This would remove some of the unknowns that hospitals question, such as who will the doctors be and whether they are committed and stable. The more bad experiences I hear circulating, the more I think this may be the way forward.
Thank you for creating a forum to discuss these topics.
Jessica Sims, MD
San Francisco, CA