ACEP President and GSACEP member Dr. Gillian Schmitz shares how we evolved to this current time in emergency medicine and priorities going forward as our specialty continues to serve patients and our nation.
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Episode Transcript
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Gillian Schmitz (00:14):
All right.
Well, good morning, everyone. Ithought we'd talk a little bit
about sort of the history andfuture of Emergency Medicine.
This is a time of a lot ofanxiety and concern about what's
happening with our specialty.
And I think a lot of what we'retalking about the issues today
are not new. In fact, we've beendoing this for kind of a long
time. And one of the best kindof learners of the future is
(00:36):
understanding where we started,and kind of how did we get here
to many of the things areaffecting us today. Someone sent
me a copy of this. And I thoughtthis was really interesting that
emergency medicine was on thecover of Time Magazine. But I
want you to look at that topleft corner there, the date
there is May 1980.
(00:57):
And the time at that time washospitals are facing critical
conditions, too many patientstoo little money, staff at risk
of burning out nursingshortages, non paying patients
drug violence, of this is acrisis, we're never going to
recover. So the more thingschange, the more things stay the
same. We've been through thisbefore. And this is part of a
course of what emergencymedicine has gone through. But
yet we're resilient, and webounce back. So it's interesting
(01:20):
when you think about medicine,how did this start? So back in
the 1700s, if you hadappendicitis, the doctor came to
your house, they actuallyoperated like in your bed, there
was no hospital, the doctor hadtheir little black bag, and they
came to your house, if you hadmoney. If you didn't have money,
there really was no health caresystem. There was sort of what
(01:42):
they call the ALMS houses. Andthe very first hospitals began
opening up in 1736. There weretwo of them charity, and shortly
after that it was Bellevue. Andfor all intents and purposes,
these were sort of homelessshelters, they dealt much more
with social determinants ofhealth than they did healthcare.
In fact, infection was rampantin many of the very first
hospitals. And then around theturn of the century, we saw the
(02:05):
sharp incline and the number ofhospitals. Well, what happened,
we had a huge influx of fundingfrom the government through it
was called the hill Burton act.
And at the same time, we beganbuilding roads and highways and
people were moving away from therural areas and into these big
cities.
We saw an influx of money fromMedicare. So finally, the
government was paying for peoplewho were 65 and older, who had
(02:27):
other comorbid diseases. Andtechnology was changing, right,
the very first CT scans, I thinkit had one cut, right, you
either had a brain yes or no,that was like the limit of
technology. But technologywasn't fitting so nicely in
those little black bags anymore.
And so people started leavingtheir hospitals or their
clinics, and going to thehospital to get their emergency
care. But the hospitals weren'tready for them yet. People
(02:49):
didn't have an emergency room.
And the very first emergencyrooms were literally called the
pit. Because we were in thebasement with these leaky
exposed pipes that were gurneysthat weren't even necessarily
private beds.
You had nurses who would comeout, you would ring a bell. In
fact, if any of you been toAndrews, there is still a bell
that you rang to get service tosee if they could even take care
(03:11):
of you. And if the nurse thoughtyou had a head bleed, if they
didn't have a neurosurgeonaround, they would just say I'm
sorry, we can't take care of youhave to go somewhere else
without having any kind ofpolicy or system of where they
needed to go.
And medical students or interns,were the ones taking care of
potentially the sickest amountof patients, it was deemed,
quote, a great place to learn.
And there was no supervision. Itwas sort of the wild west of who
(03:31):
was taking care of emergencypatients, until some people in
Jim Mills was one of them. Somaybe we could do this
differently. What if we gave upour clinics, our hours and just
focused on one specialty oftaking care of the unknown, the
acute undiagnosed patient? Andpeople thought they were crazy.
Of Why would anyone want to takecare of anyone, anywhere,
(03:52):
anytime. And many people didn'twant us to be in that space. In
fact, the surgeons push backreally hard that we were quote
the enemy, right. Nobody wantedemergency medicine. It was a
turf battle of who was going tobe in this space. And people
like Peter Rosen, who I workedwith in San Diego, and Judy
tintinalli. In North Carolina,by the way, it's very
(04:13):
intimidating, working on yourchair wrote the book of
Emergency Medicine and she wouldchase you around the emergency
department like Didn't you readmy chapter? It's like, ma'am, I
haven't gotten to that page yet.
And so we went to the ABMS, theAmerican Board of Medical
Society, and we made our pleathat emergency medicine should
be its own specialty. Anyoneknow what the results of that
(04:33):
first vote were? We lost and welost really badly. 100 to six
was the first vote if peoplewere voting against emergency
medicine being recognizedspecialty. They said we didn't
have a unique body of knowledgethat we were not a different
specialty, that we wereglorified triage doctors. And so
we had to go back to the drawingboard. We had to create research
(04:54):
we had to really get into thepolitics of medicine and fight
for our specialty and we Did andafter many years of going back
of renegotiating we path in1979, we became the 23rd
recognized specialty in thehouse of medicine.
Unknown (05:10):
So since that time ASAP has done a number of workforce
studies of looking at well, nowthat we have a specialty now
that we're finally recognized,how many emergency physicians do
we need, and when we found overtime, is that the number of EDs
have slowly decreased, althoughI put an asterisk because it
does not include freestandingemergency departments. But you
can see that the number ofresidencies has grown
(05:30):
precipitously, really over thelast 20 years in between 1999
and 2009. So in just that 10years, there were only five new
residencies. But look at thegrowth, it was almost a 50%
growth of the number ofresidents per program over that
time. And that was going becausewe were told, and we still
thought and do today that wedon't have enough physicians.
(05:52):
But how many emergencyphysicians do we need? So if we
look at these growth andprograms we've seen between even
2015 And today, there's been a30% increase in the number of
emergency medicine residencyprograms, that is a huge
increase. And it's going to betough to keep up with that
supply. And that's what causedthese initial questions of, we
(06:13):
know, we don't have enoughdoctors if we look at all
specialties, but how manyemergency physicians do we have?
And on top of that the workforceis changing. And 20% of IDI
visits are now seen by pas andnurse practitioners. And so we
need to kind of look at our ownworkforce and see how many
emergency physicians do we havetoday. So this was published in
Annals and in 2020, there werealmost 70,000 emergency
(06:33):
physicians, they did not includeresidents as being clinically
active, so only 50,000clinically active, but there's a
subset there are people who arepracticing emergency medicine
are still in the workforce, butthey're not working clinically.
And I think that's an importantpoint I'm going to come back to,
but over 70% of us are now a BIMresidency trained board
certified. And over 80% are emtrained, so their board eligible
(06:54):
but not board certified yet?
That's insane. I remember when Iwas training, only half of
Emergency Physicians wereresidency trained. So this is a
huge shift of where we areevolving as a specialty and a
great way. Today, there's almost280 residency programs. We're
about 28% women, which is sortof plateauing or even decreasing
where we were a couple of yearsago, and almost all of us
practice in urban or suburbanareas. And so last year, we did
(07:17):
a workforce report to look atthose projections. And they were
exactly that there areprojections. Whenever you do a
workforce study, it's based on anumber of assumptions of how
quickly are we growing? What isthe attrition rate out of the
workforce, nobody could havepredicted when we started this
study in 2018, that we weregoing to have a massive pandemic
that would affect people. Butbased on those projections, they
(07:40):
said, if we continue at thisrapid growth rate, if we don't
somehow change that supplydemand, we may have about 8000
More emergency physicians thanwe have jobs by 2030. And that
caused a lot of concern. Sowhere's that growth coming from?
Well, part of it on that leftside there is is the number of
em actual positions. So thenumber of programs on the right
(08:02):
side there has grown by about15%. But the bigger issue is
that residency is not only aregrowing in number, but they're
growing in size. So where theyused to have six residents, now
they're graduating eight, or 10,or 12, and people are expanding
their complement. So both ofthose things are contributing to
the increase in supply. If youlook at how big is emergency
medicine, the median is 32. Butwe now have several emergency
(08:26):
medicine residency is that havemore than 100 residents in their
class? Is that a residency or isthat a small army, right that I
can't even remember, like 30people's names much less than
you get much bigger. And so thisis a very difficult question for
us to answer. But how do wepolice this? How do we control
our own growth and do it in aresponsible manner? Well, much
of what we talked aboutyesterday, is that this is
(08:47):
driven by dollars. It's drivenby funding, and GME is what pays
for the majority of spots. Andthen they froze the cap at a
certain point in time. They saidwe're not going to pay for this
anymore. But yet we kept findingways to pay for it because it
was profitable to start aresidency. And the cap only
occurred for programs who had apreviously approved program. So
(09:08):
if you're a quote, Virginhospital, you've never had GME,
right, your Baptist Hospitaldown the street, you could just
start a residency program. Andwhen you do you have five years
to really maximize your cap. Andin some states, you get not only
national kind of federalfunding, you get state matching
funds as well. So it can be veryprofitable. Unlike orthopedic
surgery, for instance, and Ipick on them because my
(09:30):
husband's an orthopedist, it'spretty hard to start an ortho
program, because they have a lotof sub specialty cases of
certain oncology cases that theyhave to have. For emergency
medicine. It's pretty easyhonestly, to start a program
right. Every hospital alreadyhas an emergency department.
Unlike other specialties, we canpredict how many Chest Pain How
many belly pains we have comingin. And so we're looking at how
(09:50):
do we change that and how do wemake it harder? And who is
starting residency programs?
It's really everybody. It's notnecessarily Just corporate for
profit, it is for profit. It isnonprofit, it
is public hospitals, everyone isgetting into this business,
because it helps support theemergency department helps with
funding. And when we look at thepie, what makes emergency
(10:14):
medicine different is that 70%of our patients don't pay the
cost of care. No other specialtyhas that we are the only ones
that have the EMTALA mandate.
And so unlike everybody else, wecan't turn people away, we
wouldn't want to turn peopleaway. But what other businesses
could keep their doors open if70% of their customers didn't
pay for their service. And soit's putting a real strain on
(10:36):
the health care system and onemergency departments. One of
the things I think we heard thisyear, people were concerned
about the civilian match of whatwhat happened and people are
freaking out. And this is massexodus of students out of the
specialty and it's not, what Iwant to point out here is that
roughly the number of applicantsis about the same as where we've
been on par. This data was takenfrom sort of the mid match
(10:57):
season, so kind of December andreflects the previous
application cycle. So we sawkind of a bump in 2021. And that
was in December of 2020. Well,what was happening in December
of 2020, we were the healthcareheroes, everyone was banging
pots and pans, a workforcereport hadn't come out. So we
saw this kind of unusual surgein the number of people who were
(11:18):
applying to emergency medicine.
So yes, if you're only lookingat one year, there was a notable
dip in the number of applicants.
But looking at one year is notreally reflective, because that
one year was really anabnormality. If you look over
time, and really since 2017,we're about on par, we had
almost the same amount ofapplicants as we have always
had. And in fact, this year, wehad more people applying to
(11:39):
emergency medicine than we didin 2019. So it's not that the
number of students are notapplying to emergency medicine
is that we're offering too manyspots, and that we're growing
too fast. And this was whateveryone was panicking about is
unfilled, right? Because it'sbeen unprecedented that
emergency medicine wouldn't fillits spots. But you can imagine
if you have the same amount ofapplicants applying to emergency
(12:02):
medicine, or even a little bitless, but all of a sudden you've
added 80 new spots to the match,you're gonna have more spots
that are unfilled. A third ofthe programmers who didn't fill
were in Michigan, a third werein Florida or in Texas. And
those happen to be states wherewe were growing at a rate that
was probably unsustainable. Soto me, this is actually good
(12:22):
news. This is a wake up call,this is exactly what we needed
to happen to help the marketforces correct to say, maybe we
don't need to add more residencyprograms in Florida and Texas
and Michigan, maybe we're goodfor a little bit. But people
needed to see this to be able tocorrect those things and adjust.
This shows kind of the number ofapplicants over time, the purple
line is the number of applicantsand the green is the number of
(12:44):
available positions. So you cansee in 2011, only half of people
who apply to emergency medicinematched in emergency medicine.
So the good news is we have waymore applicants, we always have
the number of spots. And wecontinue to be one of the most
competitive specialties in thehouse of medicine. But over
time, if that purple line drops,right, if the number of
applicants dropped by the numberof positions go up, you're going
(13:05):
to come to a point where webecome less competitive. And
that's what we don't want tohappen, we want to recruit the
best and the brightest. And soour message has got to be that
emergency medicine is very muchthe best specialty to go into.
And we don't want to scare awayour most competitive applicants.
So what is ASAP doing to addressthis? So we've kind of coined
the phrase, the five pillars.
(13:28):
And these are things that we'redoing to address really looking
at those gaps in supply anddemand. So pillar number one is
looking at how do we raise thebar? If emergency medicine is
too easy to start? How do wemake it harder? It'd be great if
you could just put a moratoriumon the number of residency
programs and say we're justgoing to stop. But you can't do
that. Unfortunately, that's abig anti trust No, no. But we
(13:51):
can raise the bar and standards,which would make it a little
harder to create a residencyprogram. So we've been meeting
every two weeks with all of thedifferent em organizations to
talk about what is the rightnumber of procedures? Anyone
know how many intubations you'dhave to do to graduate Emergency
Medicine Residency? Yeah, but 30If it's 35, and a third of them
(14:13):
can be done on a mannequin.
Right? How much does a mannequinlike intubating someone in real
life? Well of these mannequinsare pretty good, I have to say,
but maybe there's data to showthat that number needs to be
significantly higher. Andactually, anesthesia has looked
at this. And they said, even ina controlled airway, the number
from their data of what you needto be competent was 70. So maybe
we need to actually use data asopposed to 30 Sounds like a good
(14:35):
number, which was kind of a backof a napkin math, to make it a
little bit more difficult. Andmaybe for things that are life
saving, like intubations orchest tube,
maybe those needs to be done ona live patient and not just as a
mannequin to be able to ensurethat you're getting enough
critical care and recitations tocount toward training in
emergency medicine. And do weneed to redefine what a
(14:57):
resuscitation is right now? Whatsort of nebbia That's right, we
have to do X amount of traumaresuscitation or X amount of
medical resuscitations. But somepeople are just giving an
Albuterol inhaler and steroidsin the counting that as a
medical resuscitation, I don'tthink that was what it was meant
to be. So maybe we need to be alittle bit more defined about
what our critical care is. ButI'm sensitive to the fact
especially the military, thatour acuity tends to be a little
(15:20):
bit lower, right? We don't wantto hurt our own programs. So how
do we balance that? For some ofthe recitations we have included
live pig models, so that many ofour pig labs that we're doing in
residency would count towardthat training. The point is,
that has to be something thatactually gets your hands dirty,
you can't just do everything ona mannequin, some of them like
cracks, we're going to have todo on mannequins, but looking at
(15:41):
some of the more critical careof making sure we have enough
patient encounters to make surewe're actually training to the
best efficiency going forward.
And we're looking at scalingprograms. So if you have 100
residents in your program, howmany patients? Are they actually
seeing how many core faculty doyou actually have? Are we having
enough of a ratio where they'regetting not just the clinical
time, but that right amount ofmentorship? So these are all
things that we will be proposingto the ACGME. The ACGME is kind
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of the overarching body that hasthe final say, it is made up of
people who are not emergencyphysicians, they have a lot of
questions about how we dothings, because we do things
very differently. Our wholespecialty operates very
differently than other things.
So they start to dive in on thisnext month. And we'll be looking
and picking apart all of ourrequirements to see how this is
(16:26):
going to change. We're lookingat ensuring that business
interests do not supersedeeducation or patient care. And
these events, some verydifficult conversations. But
I've met with all of thosehospitals that were on that list
that have opened residencies andsaid, Please stop. We're good.
And that's not an easyconversation. But many of them
have, we're going off olderdata, which said, we don't have
(16:50):
enough doctors. And that's truewhat we heard yesterday, there's
a huge nursing shortage. There'soverall a huge physician
shortage. When we look at oursub specialty on if you flip to
page 58 of their report. Foremergency medicine, we're kind
of getting to the point wherewe're oversaturated. And many of
them have come back and said,Well, we hear what you're
saying. And we're listening toyou and we're responding to your
feedback. And this is the powerthat ASAP has is that we can
(17:13):
talk to the CEO of HCA, we cantalk to ascension and say please
look at how you're buildingwhere you're growing too quickly
because it's having negativeconsequences. And so they're
looking at the future of notopening as many programs and
maybe even converting some oftheir GME spots to other
specialties where there is aneed psychiatry, primary care.
And we're really speaking up forthe emergency physician to
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protect our unique role that webelieve in collaborative
practice. We work very commonlywith pas and nurse
practitioners, and we believe incollaborative models, but we
believe in physician led care,and that every patient deserves
to have their care led and seenby an emergency physician, when
so part of that was joining amascope of practice partnership,
to really look at the differenceand training and to be able to
(17:57):
articulate to our legislatorswho are doing well intended
legislation, but to allowindependent practice undermines
essentially the years ofresidency and fellowship
training that we are doing, andsaying that we're different, and
that can be a good thing. We canwork together. But having a
nurse practitioner or PA workingindependently is not the right
(18:18):
thing for patients, we wantphysician led care. And last
week for doctors day, wereleased a number of videos that
show the difference in trainingbetween an MP and a PA and a
doctor. And I think this isimportant also because many of
our PA colleagues are frustratedthat they get put in a category
with nurse practitioners andtheir training is very different
(18:38):
than a nurse practitioner. Solet's be truth in advertising.
Who are we? What are we done,and what is our training. And
we've been going to statecapitals, we had a number of
victories this year in SouthDakota, in Texas and Louisiana,
of defeating legislation thatwould have allowed independent
practice, to say again, wesupport our PA and MP
colleagues, we want to worktogether but we want physician
(18:58):
led care.
pillar number four is looking atrural areas. So this has always
been a problem throughout timeas we have jobs. They're just
not necessarily where peoplehave wanted to go. The West on
the East Coast may be a littleoversaturated. But there's a
whole third of the country wherethere's not enough emergency
physicians. So how do weincentivize people to go there?
We don't have a job problem. Wehave a distribution problem. So
(19:21):
many of you signed up forscholarships of HPSP to forgive
your loans or went throughthrough uses. What if we had a
different system for us medicalstudents where they could have
loan repayment if they agreed towork in Kansas for four years
after they graduated? How do weincentivize those jobs that
would forgive some of theirmedical debt? And how do we
train our residents to havethose rural rotations so they
(19:42):
feel comfortable working inthose environments. And pillar
number five is the one I'm mostexcited about. And this is about
expanding the demand and reallyredefining who we are as a
specialty. So interestingly,we're not the first ones to go
through this. Anesthesia had ahuge surplus in the 80s where
everyone was wanting to go intoanesthesia. And what happened at
that time is they had managedcare. And they said back then
(20:04):
boy with managed care, we're notgoing to have as many elective
surgeries, we don't need to haveas many or cases. And what
happened, people panic medicalstudents stopped applying to
anesthesia. And for a coupleyears 50% of their applicants
were international medicalstudents, because the demand
from us medical students kind ofplummeted, which is what we're
concerning that we're facing inemergency medicine. So how did
(20:25):
they change that? Well, theyredefine what they did. They
said we have to now do more thanjust airway right, we have to
expand and to pain management,we have to get outside of the or
they began opening ambulatorysurgical centers expanding their
practice. Today, 50% of ananesthesiologist job is outside
of the or, and so they reallydefined who they became. And
(20:47):
emergency medicine is at thisunique point where we can define
who we are, maybe it'stelemedicine, maybe it's urgent
cares, maybe it is home health,and after people are discharged,
maybe it's freestandingemergency departments and taking
us outside of those four wallsof a hospital and using our
skill sets and other places.
This is a very care. Theyoversee 150 critical access
hospitals where you work fromhome. I know Dr. Austin has done
(21:08):
this where she can order labsand see a patient through
telemedicine and disbelievethem. This is down the street
from me in San Antonio of aneighborhood hospital. Right.
It's sort of an emergencydepartment on steroids where
they have an an MRI, ultrasoundCT scan, that really what we
become as rapid diagnosticcenters, many of the things we
used to admit TAS P E's. Maybesome of those can actually be
(21:30):
observed and go home. And thatcan be a growing role of what
emergency medicine can be. Andmany people are expanding beyond
their roles traditionally ofworking in the emergency
department and getting intoother aspects. Dr. Kellerman,
who was a dean at USUS is nowone of the first emergency
medicines who is a CMO of amajor hospital and health
system. We havea bunch of people who are in the
(21:51):
White House, Dr. Rodriguez hasbeen on the COVID-19 response
task force. So I do thinkthere's a lot of light at the
tunnel, there's so many goodthings coming for our specialty,
that what I want everyone totake home from this is take a
deep breath, it's going to beokay, the world is not falling.
And I've really come to theconclusion that life is all
about attitude. And if you lookat social media, it is
(22:12):
exhausting. And it drains ourenergy because people are always
thinking, the world is endingthe specialty is over. That is
completely untrue. We are in areally good place. And I believe
it is. And I keep going back tomy TED lasso, because it's all
about belief is about believingin a bigger purpose and kindness
and knowing that it's going tobe fine and seeing the longer
(22:33):
vision of where we are as aspecialty. And how do I know
this? And why am I sooptimistic. So this past year,
we spent a ridiculous amount oftime doing strategic planning.
And we were asked to take a.wehad a red dot and a blue dot.
And the board was asked to puton one end we said specialty of
what should ASAP advocate forand then the other end
(22:54):
physician. And know that whenASAP started, as we talked about
it was because the specialtydidn't exist. And so ASAPs
purpose was to defend and createa specialty. And much of what we
were doing was focused onspecialty. And so we all put red
dots kind of between that lineof physician and specialty,
where do we think we are today.
(23:15):
And you can see those red dotson the top. But we were
somewhere in the middle, butleaning a little bit more toward
the specialty. And we talkedabout the blue dot, where do we
need to go? What does the futurelook like? And you can see
that's a pretty notable change.
And I will say even in the fiveyears that I've been on the
board, it was very difficult topivot away from specialty care.
But I make the analogy that yes,our primary mission is about
(23:36):
patients. Yes, the primary thingis about specialty, but you have
to put on your own oxygen mask,right when you're on an airplane
before you put on your child'smask, we have to take care of
ourselves. Because ultimately werepresent emergency physicians
and if we are not advocating forthem and having their back,
we're going to lose people thisneeds to be our focus. And this
was a really aha moment I thinkof a strategic pivot, and what
(23:57):
our mission is going to be tosome of the things I'm most
proud of. Over the summer lastyear, we created a term of what
is an emergency medicineresidency, and that many people
are using this term in theirtraining, but it is not
equivalent to physiciantraining. So asepsis position is
that the term resident andresidency training should apply
only to postgraduate training ofphysicians that we have other
(24:20):
programs for pas for nursepractitioners and pharmacists.
But that words matter, we needto start really differentiating
ourselves from many of ourcolleagues of what our training
is. We've really tried to honedown on what is the right form
of supervision. And this hasbeen a huge challenge. But one
of the things that I'm sort ofmost proud of is is let's start
looking at this what is theright amount of supervision? So
(24:40):
we had a taskforce last yearthat was made up of samba for
the PAs and the nursepractitioners and every em
organization and we've goteveryone in a room and said can
we agree on what definitions areand what is the right level of
supervision? And the group cameup with these definitions. That
direct supervision is What I dowith my residence, right, they
tell me about every patient, Ihave to see every patient and I
(25:02):
have to document every patient,indirect supervision as if
someone discusses the care withme. But I don't necessarily see
the patient, but I hear aboutthem. We talk about the
management in real time beforethe patient is discharged. And
that could either be on site, ifyou're physically in the IDI, or
potentially off site, if you'redoing it through telemedicine.
And there was this category ofsort of oversights, where a PA
(25:25):
or NP could decide whichpatients to present that the
emergency physician is availablefor consultation, but only as
needed. And they would notnecessarily know about the
patient in real time. But theywould review the chart after the
patient was discharged. And ASAPreally has grappled with this of
what do we recommend and what isour policy. And so last month,
(25:46):
we reviewed this and wedetermined that we don't believe
oversight is supervision. It isquality review. If you're
looking at a chart after thefact that that doesn't
constitute supervision. And ifwe're really trying to say we
want the highest level of care,we do feel that at least in a
minimum, indirect supervision isappropriate where you're hearing
about the patient, even if it'sjust hey, I've got a lack in
(26:07):
room five, I'm going to sew itup and send them home with after
a tetanus shot. But I have toknow about that patient before
they're discharged. And wetalked about off site really
only being appropriate for ruralemergency departments or
critical access hospitals whereyou couldn't get an emergency
physician. But that offsitesupervision was not appropriate
for urban, suburban or academichospitals.
(26:29):
We launched a campaign on thevalue of emergency physician of
really what is that differencein training, and to really help
with our scope of practicebattles that are at a state
level, and arguing that we agreeon physician led care of team
based care that everyone plays avery important role in emergency
medicine, but that an emergencyphysician needs to be involved
with every care of patients inthe emergency department.
(26:51):
Another big concern people arehaving is the degree of
consolidation in medicine. Wetalked about this a little bit
at dinner last night. But howmany people remember Blockbuster
video? Remember, we used to havea card and you have done Friday
nights and rent videos a littlelike be kind please rewind. So
what what happened? Whathappened to Blockbuster Video?
Apparently, there's oneBlockbuster video that's still
(27:11):
open. Where's the blockbusterthat's open now? Oregon.
Interesting. Okay. Well, inTexas, I'm not even kidding.
They're all now freestandingemergency departments. And what
I used to work on was a formerblockbuster. So what happened to
Blockbuster, right, the worldevolved around it, we went to
Netflix, we went to streaming wewent to Apple TV, that there was
not a need for renting videosanymore. The way things are
(27:34):
evolving in a capitalisticsociety like the United States
is that things are growingbecause that scale works, right?
You have Home Depot has replacedthe mom and pop hardware stores.
Amazon has put Babies R Us outof business. Things are
changing, things areconsolidating, because from a
business perspective that whatwas needed to be realistic to be
(27:55):
relevant to be able to stay inbusiness. And again, a 70% of
your patients don't pay the costof care. How do you keep your
doors open? The only way to dothat is to scale both
horizontally and vertically. Sowhat does that mean? So
horizontal integration is if Ihave one small group that buys
out another small group, or Ihave one hospital that buys
another hospital. And now in thehealth system. Vertical
(28:17):
integration is when you have aemployer who is not just
emergency medicine anymore, butthey buy radiology, they buy
anesthesia, they buy thehospitalist because they can
scale those costs, right?
Instead of having five differentmedical directors and benefit
managers, you have one. So thereis some benefit to that. And
that is the model that hasreally succeeded, if you will,
in the marketplace. And thoseare market forces that are
(28:41):
driving that. Anyone know howmany small groups are left in
emergency medicine that haveover 60,000 patients? It's about
150. They're left in the wholecountry. And so we're seeing
this increase consolidation isnot just for big groups, it's
hospitals and health systems andacademia that are invested
sometimes with private equity,sometimes with venture
(29:02):
capitalism, but getting thatfunding to keep that business
model sustainable. So they don'tbecome blockbuster. But what
does that impact ofconsolidation? How does that
have an effect on our practice?
People are concerned that asthings have become more and more
consolidated, that we have sortof less control of our practices
of what is the impact on oursalaries. So I will tell you,
(29:23):
the group that I used tomoonlight for and do odd with
got bought out by a big group.
And I asked them what haschanged. They actually all make
the same amount of moneyactually, many of them make more
than they used to. They arestaffing has not changed, but
they don't make those decisionsanymore about what is the
staffing in the emergencydepartment. How many patients an
hour Am I seeing? And peoplefeel frustrated by that lack of
(29:44):
control. And we're seeing thatnot only in corporate groups,
but even in academic groups inother health and hospital
systems in the community. Asthings have gotten bigger, we
have less and less control overthose individual decisions. So
the FTC the Fed When TradeCommission has come out and
said, We are concerned that thisis happening across all
spectrums of too muchconsolidation, not just in
(30:05):
healthcare, but in Google andAmazon and Disney, right? All of
these things are bigger isbetter. But is it? We want to
know what the impact is onconsolidation, tell us your
stories. And so ASAP met withthem. And they asked us to put
together a letter. And so wehave until April 15. So if
you're in a group that has beenconsolidated, we want to know,
how has it impacted your salary?
(30:27):
How has it impacted yourautonomy? How has it impacted
your ability to care forpatients, and we're compiling
those results of the FTC canmake stronger guidelines to look
at vertical and horizontalmergers. And just this
yesterday, we passed a newstatement on private equity and
corporate investment inemergency medicine. That says we
are increasingly concerned aboutthe expanding presence of
(30:48):
private equity and corporateinvestment in healthcare, that
we are concerned that this isimpacting our ability to have
autonomy in our practice, andthat this needs increased
scrutiny, and how we reallyreport care and how we take care
of patients and betterunderstanding the impact of cost
of quality and a physicianautonomy. And we're really
calling for more transparency,because that's what it comes
(31:09):
down to is not just who is youremployer, they quote good or
bad, but what are theirbehaviors? Not all private
equity groups are bad. Not allacademic groups are good. We
tend to put people in thesebuckets. But really, we should
ask, what is your contract looklike? Do you have due process
if you were to get fired?
Because you spoke up about nothaving PPE or there was a
patient? Who is risk? Are youallowed to do that? Are you
(31:32):
going to get fired for puttingyour neck out? Do you see what's
billed and collected under yourname, or you have a non compete
clause where if I lose my job, Ican't work in a certain area.
All of those things are areharmful to physicians. And we
have always advocated for thehighest ability practice and
those good behaviors. And so oneway we've changed this year was
to create this checklist. Sothat anyone that exhibits or
(31:54):
sponsors or works with ASAP isasked to fill this out. So you
can scan them with a QR codewhen you walk around the exhibit
hall. And you can see exactlywhat they offer and what they
don't. With the idea being thatif you have increased
transparency, you can decidewhat's best for you. Right? Some
people in this group, they don'tcare about billing transparency,
they could care less what'sbuilt in their name, but they
(32:14):
want a good maternity policy.
Right? Somebody else reallyfeels strongly about due
process, but could care lessabout CME reimbursement. So I
can't tell you what is good andwhat is bad. I can only tell you
what they offer. And you shoulddecide what job works for you.
We've had a number of hugelegislative wins this year. So
in Georgia, we had a lawsuitagainst BlueCross BlueShield.
(32:37):
They have a list of diagnoses,that if you put on your chart,
they would say we're not goingto pay you for that, because
that didn't really need to bethere. So chest pain guy comes
in with chest pain, shortness ofbreath, you work them up, right?
Everything's normal, their heartscores low, they go home, your
diagnosis is noncardiac chestpain. Well, the insurance
company was coming back andsaying, Well, Gillian, that's on
(32:58):
my list of 800 things that arenot an emergency. So that
patient didn't need to be there.
I'm not going to pay for it. Andwe said, well, that's kind of
BS, right? Because we don't knowwhen the patient comes in. If
they have noncardiac, chest painor something else, we should be
looking at their presentation,not on their final diagnosis.
But yet that was the plan thatBlueCross BlueShield. They had a
list of 800 things whichincluded chest pain, asthma,
DKA, vaginal bleeding, it wenton and on of all things, they
(33:22):
didn't consider emergencies. Sowe said, that's fine. We're
going to sue you. How do youlike that. And we want and that
was a big deal of how we applythis now that retrospectively,
they can't use this list ofthings to say that they're not
going to pay for something. InVirginia, they had the same
battle this year, with Medicarenot reimbursing for services, if
it meant a secret list of about500 different diagnoses. And our
(33:43):
position has always been youcan't use a final diagnosis to
determine what is an emergency.
And what is not a nationallevel, we had a huge win this
year. So out of network, which Iwon't go into the details of but
effectively this put another 50to $100,000 in every emergency
medicine physicians pocket inthe civilian side, because it
(34:06):
had this law gone into act, itwould have allowed the insurers
to decide what to pay you. Soessentially, if you are in the
community, you're doing od E andyou see a patient and you say
it's a chest pain, I'm going tocharge $100 Right, the insurance
company was coming back andsaying, We'll give you $5 And
you're like $5 I can't keep mylights on. I can't pay for my
(34:26):
nurses. I can't get my CTscanner. That's ridiculous. And
the insurance company says Takeit or leave it. Here's five
bucks if you want to be out ofnetwork that's on you. But our
in network rate is $5. So yousay okay, well, that kind of
stinks. I guess I'll be out ofnetwork because I can't keep my
lights on for $5. Well, whathappens if you're out of
network? There is no process toadjudicate what is a fair price
(34:48):
when he baseball players in theaudience. I'm not a baseball
player, but I learned a lotabout the MLB. So when they
negotiate their contracts, theycome out and say I think I'm
worth $10 million and the Thebaseball league says no, you're
worth a million. The arbitratordoesn't average them, they have
to pick one or the other of whatthey think they're worth. And so
(35:08):
incentivizes both people to cometo a reasonable offer. So what
we advocated for is, well, let'sdo a baseball style arbitration.
So if I come and I say, I thinkthe price is $100, and the
insurance company says it'sfive, the arbitrator would have
to pick one or the other, notaverage, the two. And if the
insurance comes back withsomething that's so ridiculous,
they're gonna pay us what we'reasking for. And that was the law
(35:31):
that got passed is we're gonnahave this arbitration process,
which was a huge win foremergency medicine. But when it
got implemented into actuallyhow it was going to be carried
out, the devil is always in thedetails. The government said,
we're gonna leave it up to theinsurers to decide what a fair
rate is, well, whatare the insurance companies
going to do? Right, they'realways going to do something
that saves the money. So we suedthe federal government, which is
(35:52):
an awkward position when youwork for the federal government.
But it was a step not me. Andagain, that's the value of Asa
because it gives you coverage,right? So you can advocate for
us as physicians, and much ofwhat that talk was yesterday, it
helps give us a voice that wecan make changes. So we sued,
and we sued across the country.
And we did it with theanesthesiologist and the
radiologists. It was a wellcoordinated effort across the
(36:14):
country in multiple differentstates with the same premise
that we are suing because thisis an unfair process. And
recently, we won in Texas and sothe government is now backing
off and having to come back withwhat is their new rule of how
they're going to pay for healthcare. And most excited as we
pass the Lorna Breen act, formany people who don't know Lorna
(36:34):
Breen, she was an emergencyphysician who took her own life
in the middle of the COVIDpandemic. And she had no history
of mental illness. She was byall accounts healthy, happy
medical director, and tragicallytook her own life. And this is a
topic we need to really startgiving more attention to. We
have stigmatize mental health,we have made it not okay for
(36:56):
people to ask for help. And weare seeing record number of
physician suicides, residentsuicides, that we need to start
advocating for more resourcesfor destigmatizing being able to
ask for help when we're notokay. And we got this passed
into law just a couple of weeksago. So yes, we have a number of
short term challenges. Bring iton. That is what we do. We're
(37:20):
not afraid of challenges. We'vehad challenges our entire
lifespan as a specialty, we weretold by people that we were the
enemy that we would never exist.
And every time we got punched inthe face, we got right back up,
because this is who we are. Andthis is what we do. So are there
going to be some short termchallenges? Yeah, I'm not afraid
of that. We've always had shortterm challenges workforce scope
(37:40):
of practice all theselegislation out of network
billing, we go back to the coreof of who we are and why we got
in this to begin with. And thatwas to help patients. It was to
be there when nobody else isthere at two o'clock in the
morning, to be the bestphysicians we can possibly be to
provide our care for patients.
And about being the mostresilient specialty there is,
(38:02):
there are going to be times weget kicked down. That's okay, we
can get right back up andlearning to really bend with the
wind and not break in the storm.
And so I see a very brightfuture for emergency medicine.
I'm very encouraged by all thethings we just talked about of
ways that ACF is strategicallypivoting to address each and
every one of those issues. Andto look forward. There are going
to be some short term volatilityfor sure there is but long term
(38:23):
goals and where we're going as aspecialty is we're heading in
the right direction and I see avery bright future for our
specialty and I couldn't be moreproud to serve as president of
both this chapter and nationalASAP and I thank you very very
much for your time.
All right.
Well, good morning, everyone. Ithought we'd talk a little bit
about sort of the history andfuture of Emergency Medicine.
This is a time of a lot ofanxiety and concern about what's
happening with our specialty.
And I think a lot of what we'retalking about the issues today
are not new. In fact, we've beendoing this for kind of a long
time. And one of the best kindof learners of the future is
(00:36):
understanding where we started,and kind of how did we get here
to many of the things areaffecting us today. Someone sent
me a copy of this. And I thoughtthis was really interesting that
emergency medicine was on thecover of Time Magazine. But I
want you to look at that topleft corner there, the date
there is May 1980.
(00:57):
And the time at that time washospitals are facing critical
conditions, too many patientstoo little money, staff at risk
of burning out nursingshortages, non paying patients
drug violence, of this is acrisis, we're never going to
recover. So the more thingschange, the more things stay the
same. We've been through thisbefore. And this is part of a
course of what emergencymedicine has gone through. But
yet we're resilient, and webounce back. So it's interesting
(01:20):
when you think about medicine,how did this start? So back in
the 1700s, if you hadappendicitis, the doctor came to
your house, they actuallyoperated like in your bed, there
was no hospital, the doctor hadtheir little black bag, and they
came to your house, if you hadmoney. If you didn't have money,
there really was no health caresystem. There was sort of what
(01:42):
they call the ALMS houses. Andthe very first hospitals began
opening up in 1736. There weretwo of them charity, and shortly
after that it was Bellevue. Andfor all intents and purposes,
these were sort of homelessshelters, they dealt much more
with social determinants ofhealth than they did healthcare.
In fact, infection was rampantin many of the very first
hospitals. And then around theturn of the century, we saw the
(02:05):
sharp incline and the number ofhospitals. Well, what happened,
we had a huge influx of fundingfrom the government through it
was called the hill Burton act.
And at the same time, we beganbuilding roads and highways and
people were moving away from therural areas and into these big
cities.
We saw an influx of money fromMedicare. So finally, the
government was paying for peoplewho were 65 and older, who had
(02:27):
other comorbid diseases. Andtechnology was changing, right,
the very first CT scans, I thinkit had one cut, right, you
either had a brain yes or no,that was like the limit of
technology. But technologywasn't fitting so nicely in
those little black bags anymore.
And so people started leavingtheir hospitals or their
clinics, and going to thehospital to get their emergency
care. But the hospitals weren'tready for them yet. People
(02:49):
didn't have an emergency room.
And the very first emergencyrooms were literally called the
pit. Because we were in thebasement with these leaky
exposed pipes that were gurneysthat weren't even necessarily
private beds.
You had nurses who would comeout, you would ring a bell. In
fact, if any of you been toAndrews, there is still a bell
that you rang to get service tosee if they could even take care
(03:11):
of you. And if the nurse thoughtyou had a head bleed, if they
didn't have a neurosurgeonaround, they would just say I'm
sorry, we can't take care of youhave to go somewhere else
without having any kind ofpolicy or system of where they
needed to go.
And medical students or interns,were the ones taking care of
potentially the sickest amountof patients, it was deemed,
quote, a great place to learn.
And there was no supervision. Itwas sort of the wild west of who
(03:31):
was taking care of emergencypatients, until some people in
Jim Mills was one of them. Somaybe we could do this
differently. What if we gave upour clinics, our hours and just
focused on one specialty oftaking care of the unknown, the
acute undiagnosed patient? Andpeople thought they were crazy.
Of Why would anyone want to takecare of anyone, anywhere,
(03:52):
anytime. And many people didn'twant us to be in that space. In
fact, the surgeons push backreally hard that we were quote
the enemy, right. Nobody wantedemergency medicine. It was a
turf battle of who was going tobe in this space. And people
like Peter Rosen, who I workedwith in San Diego, and Judy
tintinalli. In North Carolina,by the way, it's very
(04:13):
intimidating, working on yourchair wrote the book of
Emergency Medicine and she wouldchase you around the emergency
department like Didn't you readmy chapter? It's like, ma'am, I
haven't gotten to that page yet.
And so we went to the ABMS, theAmerican Board of Medical
Society, and we made our pleathat emergency medicine should
be its own specialty. Anyoneknow what the results of that
(04:33):
first vote were? We lost and welost really badly. 100 to six
was the first vote if peoplewere voting against emergency
medicine being recognizedspecialty. They said we didn't
have a unique body of knowledgethat we were not a different
specialty, that we wereglorified triage doctors. And so
we had to go back to the drawingboard. We had to create research
(04:54):
we had to really get into thepolitics of medicine and fight
for our specialty and we Did andafter many years of going back
of renegotiating we path in1979, we became the 23rd
recognized specialty in thehouse of medicine.
Unknown (05:10):
So since that time ASAP has done a number of workforce
studies of looking at well, nowthat we have a specialty now
that we're finally recognized,how many emergency physicians do
we need, and when we found overtime, is that the number of EDs
have slowly decreased, althoughI put an asterisk because it
does not include freestandingemergency departments. But you
can see that the number ofresidencies has grown
(05:30):
precipitously, really over thelast 20 years in between 1999
and 2009. So in just that 10years, there were only five new
residencies. But look at thegrowth, it was almost a 50%
growth of the number ofresidents per program over that
time. And that was going becausewe were told, and we still
thought and do today that wedon't have enough physicians.
(05:52):
But how many emergencyphysicians do we need? So if we
look at these growth andprograms we've seen between even
2015 And today, there's been a30% increase in the number of
emergency medicine residencyprograms, that is a huge
increase. And it's going to betough to keep up with that
supply. And that's what causedthese initial questions of, we
(06:13):
know, we don't have enoughdoctors if we look at all
specialties, but how manyemergency physicians do we have?
And on top of that the workforceis changing. And 20% of IDI
visits are now seen by pas andnurse practitioners. And so we
need to kind of look at our ownworkforce and see how many
emergency physicians do we havetoday. So this was published in
Annals and in 2020, there werealmost 70,000 emergency
(06:33):
physicians, they did not includeresidents as being clinically
active, so only 50,000clinically active, but there's a
subset there are people who arepracticing emergency medicine
are still in the workforce, butthey're not working clinically.
And I think that's an importantpoint I'm going to come back to,
but over 70% of us are now a BIMresidency trained board
certified. And over 80% are emtrained, so their board eligible
(06:54):
but not board certified yet?
That's insane. I remember when Iwas training, only half of
Emergency Physicians wereresidency trained. So this is a
huge shift of where we areevolving as a specialty and a
great way. Today, there's almost280 residency programs. We're
about 28% women, which is sortof plateauing or even decreasing
where we were a couple of yearsago, and almost all of us
practice in urban or suburbanareas. And so last year, we did
(07:17):
a workforce report to look atthose projections. And they were
exactly that there areprojections. Whenever you do a
workforce study, it's based on anumber of assumptions of how
quickly are we growing? What isthe attrition rate out of the
workforce, nobody could havepredicted when we started this
study in 2018, that we weregoing to have a massive pandemic
that would affect people. Butbased on those projections, they
(07:40):
said, if we continue at thisrapid growth rate, if we don't
somehow change that supplydemand, we may have about 8000
More emergency physicians thanwe have jobs by 2030. And that
caused a lot of concern. Sowhere's that growth coming from?
Well, part of it on that leftside there is is the number of
em actual positions. So thenumber of programs on the right
(08:02):
side there has grown by about15%. But the bigger issue is
that residency is not only aregrowing in number, but they're
growing in size. So where theyused to have six residents, now
they're graduating eight, or 10,or 12, and people are expanding
their complement. So both ofthose things are contributing to
the increase in supply. If youlook at how big is emergency
medicine, the median is 32. Butwe now have several emergency
(08:26):
medicine residency is that havemore than 100 residents in their
class? Is that a residency or isthat a small army, right that I
can't even remember, like 30people's names much less than
you get much bigger. And so thisis a very difficult question for
us to answer. But how do wepolice this? How do we control
our own growth and do it in aresponsible manner? Well, much
of what we talked aboutyesterday, is that this is
(08:47):
driven by dollars. It's drivenby funding, and GME is what pays
for the majority of spots. Andthen they froze the cap at a
certain point in time. They saidwe're not going to pay for this
anymore. But yet we kept findingways to pay for it because it
was profitable to start aresidency. And the cap only
occurred for programs who had apreviously approved program. So
(09:08):
if you're a quote, Virginhospital, you've never had GME,
right, your Baptist Hospitaldown the street, you could just
start a residency program. Andwhen you do you have five years
to really maximize your cap. Andin some states, you get not only
national kind of federalfunding, you get state matching
funds as well. So it can be veryprofitable. Unlike orthopedic
surgery, for instance, and Ipick on them because my
(09:30):
husband's an orthopedist, it'spretty hard to start an ortho
program, because they have a lotof sub specialty cases of
certain oncology cases that theyhave to have. For emergency
medicine. It's pretty easyhonestly, to start a program
right. Every hospital alreadyhas an emergency department.
Unlike other specialties, we canpredict how many Chest Pain How
many belly pains we have comingin. And so we're looking at how
(09:50):
do we change that and how do wemake it harder? And who is
starting residency programs?
It's really everybody. It's notnecessarily Just corporate for
profit, it is for profit. It isnonprofit, it
is public hospitals, everyone isgetting into this business,
because it helps support theemergency department helps with
funding. And when we look at thepie, what makes emergency
(10:14):
medicine different is that 70%of our patients don't pay the
cost of care. No other specialtyhas that we are the only ones
that have the EMTALA mandate.
And so unlike everybody else, wecan't turn people away, we
wouldn't want to turn peopleaway. But what other businesses
could keep their doors open if70% of their customers didn't
pay for their service. And soit's putting a real strain on
(10:36):
the health care system and onemergency departments. One of
the things I think we heard thisyear, people were concerned
about the civilian match of whatwhat happened and people are
freaking out. And this is massexodus of students out of the
specialty and it's not, what Iwant to point out here is that
roughly the number of applicantsis about the same as where we've
been on par. This data was takenfrom sort of the mid match
(10:57):
season, so kind of December andreflects the previous
application cycle. So we sawkind of a bump in 2021. And that
was in December of 2020. Well,what was happening in December
of 2020, we were the healthcareheroes, everyone was banging
pots and pans, a workforcereport hadn't come out. So we
saw this kind of unusual surgein the number of people who were
(11:18):
applying to emergency medicine.
So yes, if you're only lookingat one year, there was a notable
dip in the number of applicants.
But looking at one year is notreally reflective, because that
one year was really anabnormality. If you look over
time, and really since 2017,we're about on par, we had
almost the same amount ofapplicants as we have always
had. And in fact, this year, wehad more people applying to
(11:39):
emergency medicine than we didin 2019. So it's not that the
number of students are notapplying to emergency medicine
is that we're offering too manyspots, and that we're growing
too fast. And this was whateveryone was panicking about is
unfilled, right? Because it'sbeen unprecedented that
emergency medicine wouldn't fillits spots. But you can imagine
if you have the same amount ofapplicants applying to emergency
(12:02):
medicine, or even a little bitless, but all of a sudden you've
added 80 new spots to the match,you're gonna have more spots
that are unfilled. A third ofthe programmers who didn't fill
were in Michigan, a third werein Florida or in Texas. And
those happen to be states wherewe were growing at a rate that
was probably unsustainable. Soto me, this is actually good
(12:22):
news. This is a wake up call,this is exactly what we needed
to happen to help the marketforces correct to say, maybe we
don't need to add more residencyprograms in Florida and Texas
and Michigan, maybe we're goodfor a little bit. But people
needed to see this to be able tocorrect those things and adjust.
This shows kind of the number ofapplicants over time, the purple
line is the number of applicantsand the green is the number of
(12:44):
available positions. So you cansee in 2011, only half of people
who apply to emergency medicinematched in emergency medicine.
So the good news is we have waymore applicants, we always have
the number of spots. And wecontinue to be one of the most
competitive specialties in thehouse of medicine. But over
time, if that purple line drops,right, if the number of
applicants dropped by the numberof positions go up, you're going
(13:05):
to come to a point where webecome less competitive. And
that's what we don't want tohappen, we want to recruit the
best and the brightest. And soour message has got to be that
emergency medicine is very muchthe best specialty to go into.
And we don't want to scare awayour most competitive applicants.
So what is ASAP doing to addressthis? So we've kind of coined
the phrase, the five pillars.
(13:28):
And these are things that we'redoing to address really looking
at those gaps in supply anddemand. So pillar number one is
looking at how do we raise thebar? If emergency medicine is
too easy to start? How do wemake it harder? It'd be great if
you could just put a moratoriumon the number of residency
programs and say we're justgoing to stop. But you can't do
that. Unfortunately, that's abig anti trust No, no. But we
(13:51):
can raise the bar and standards,which would make it a little
harder to create a residencyprogram. So we've been meeting
every two weeks with all of thedifferent em organizations to
talk about what is the rightnumber of procedures? Anyone
know how many intubations you'dhave to do to graduate Emergency
Medicine Residency? Yeah, but 30If it's 35, and a third of them
(14:13):
can be done on a mannequin.
Right? How much does a mannequinlike intubating someone in real
life? Well of these mannequinsare pretty good, I have to say,
but maybe there's data to showthat that number needs to be
significantly higher. Andactually, anesthesia has looked
at this. And they said, even ina controlled airway, the number
from their data of what you needto be competent was 70. So maybe
we need to actually use data asopposed to 30 Sounds like a good
(14:35):
number, which was kind of a backof a napkin math, to make it a
little bit more difficult. Andmaybe for things that are life
saving, like intubations orchest tube,
maybe those needs to be done ona live patient and not just as a
mannequin to be able to ensurethat you're getting enough
critical care and recitations tocount toward training in
emergency medicine. And do weneed to redefine what a
(14:57):
resuscitation is right now? Whatsort of nebbia That's right, we
have to do X amount of traumaresuscitation or X amount of
medical resuscitations. But somepeople are just giving an
Albuterol inhaler and steroidsin the counting that as a
medical resuscitation, I don'tthink that was what it was meant
to be. So maybe we need to be alittle bit more defined about
what our critical care is. ButI'm sensitive to the fact
especially the military, thatour acuity tends to be a little
(15:20):
bit lower, right? We don't wantto hurt our own programs. So how
do we balance that? For some ofthe recitations we have included
live pig models, so that many ofour pig labs that we're doing in
residency would count towardthat training. The point is,
that has to be something thatactually gets your hands dirty,
you can't just do everything ona mannequin, some of them like
cracks, we're going to have todo on mannequins, but looking at
(15:41):
some of the more critical careof making sure we have enough
patient encounters to make surewe're actually training to the
best efficiency going forward.
And we're looking at scalingprograms. So if you have 100
residents in your program, howmany patients? Are they actually
seeing how many core faculty doyou actually have? Are we having
enough of a ratio where they'regetting not just the clinical
time, but that right amount ofmentorship? So these are all
things that we will be proposingto the ACGME. The ACGME is kind
(16:04):
of the overarching body that hasthe final say, it is made up of
people who are not emergencyphysicians, they have a lot of
questions about how we dothings, because we do things
very differently. Our wholespecialty operates very
differently than other things.
So they start to dive in on thisnext month. And we'll be looking
and picking apart all of ourrequirements to see how this is
(16:26):
going to change. We're lookingat ensuring that business
interests do not supersedeeducation or patient care. And
these events, some verydifficult conversations. But
I've met with all of thosehospitals that were on that list
that have opened residencies andsaid, Please stop. We're good.
And that's not an easyconversation. But many of them
have, we're going off olderdata, which said, we don't have
(16:50):
enough doctors. And that's truewhat we heard yesterday, there's
a huge nursing shortage. There'soverall a huge physician
shortage. When we look at oursub specialty on if you flip to
page 58 of their report. Foremergency medicine, we're kind
of getting to the point wherewe're oversaturated. And many of
them have come back and said,Well, we hear what you're
saying. And we're listening toyou and we're responding to your
feedback. And this is the powerthat ASAP has is that we can
(17:13):
talk to the CEO of HCA, we cantalk to ascension and say please
look at how you're buildingwhere you're growing too quickly
because it's having negativeconsequences. And so they're
looking at the future of notopening as many programs and
maybe even converting some oftheir GME spots to other
specialties where there is aneed psychiatry, primary care.
And we're really speaking up forthe emergency physician to
(17:35):
protect our unique role that webelieve in collaborative
practice. We work very commonlywith pas and nurse
practitioners, and we believe incollaborative models, but we
believe in physician led care,and that every patient deserves
to have their care led and seenby an emergency physician, when
so part of that was joining amascope of practice partnership,
to really look at the differenceand training and to be able to
(17:57):
articulate to our legislatorswho are doing well intended
legislation, but to allowindependent practice undermines
essentially the years ofresidency and fellowship
training that we are doing, andsaying that we're different, and
that can be a good thing. We canwork together. But having a
nurse practitioner or PA workingindependently is not the right
(18:18):
thing for patients, we wantphysician led care. And last
week for doctors day, wereleased a number of videos that
show the difference in trainingbetween an MP and a PA and a
doctor. And I think this isimportant also because many of
our PA colleagues are frustratedthat they get put in a category
with nurse practitioners andtheir training is very different
(18:38):
than a nurse practitioner. Solet's be truth in advertising.
Who are we? What are we done,and what is our training. And
we've been going to statecapitals, we had a number of
victories this year in SouthDakota, in Texas and Louisiana,
of defeating legislation thatwould have allowed independent
practice, to say again, wesupport our PA and MP
colleagues, we want to worktogether but we want physician
(18:58):
led care.
pillar number four is looking atrural areas. So this has always
been a problem throughout timeas we have jobs. They're just
not necessarily where peoplehave wanted to go. The West on
the East Coast may be a littleoversaturated. But there's a
whole third of the country wherethere's not enough emergency
physicians. So how do weincentivize people to go there?
We don't have a job problem. Wehave a distribution problem. So
(19:21):
many of you signed up forscholarships of HPSP to forgive
your loans or went throughthrough uses. What if we had a
different system for us medicalstudents where they could have
loan repayment if they agreed towork in Kansas for four years
after they graduated? How do weincentivize those jobs that
would forgive some of theirmedical debt? And how do we
train our residents to havethose rural rotations so they
(19:42):
feel comfortable working inthose environments. And pillar
number five is the one I'm mostexcited about. And this is about
expanding the demand and reallyredefining who we are as a
specialty. So interestingly,we're not the first ones to go
through this. Anesthesia had ahuge surplus in the 80s where
everyone was wanting to go intoanesthesia. And what happened at
that time is they had managedcare. And they said back then
(20:04):
boy with managed care, we're notgoing to have as many elective
surgeries, we don't need to haveas many or cases. And what
happened, people panic medicalstudents stopped applying to
anesthesia. And for a coupleyears 50% of their applicants
were international medicalstudents, because the demand
from us medical students kind ofplummeted, which is what we're
concerning that we're facing inemergency medicine. So how did
(20:25):
they change that? Well, theyredefine what they did. They
said we have to now do more thanjust airway right, we have to
expand and to pain management,we have to get outside of the or
they began opening ambulatorysurgical centers expanding their
practice. Today, 50% of ananesthesiologist job is outside
of the or, and so they reallydefined who they became. And
(20:47):
emergency medicine is at thisunique point where we can define
who we are, maybe it'stelemedicine, maybe it's urgent
cares, maybe it is home health,and after people are discharged,
maybe it's freestandingemergency departments and taking
us outside of those four wallsof a hospital and using our
skill sets and other places.
This is a very care. Theyoversee 150 critical access
hospitals where you work fromhome. I know Dr. Austin has done
(21:08):
this where she can order labsand see a patient through
telemedicine and disbelievethem. This is down the street
from me in San Antonio of aneighborhood hospital. Right.
It's sort of an emergencydepartment on steroids where
they have an an MRI, ultrasoundCT scan, that really what we
become as rapid diagnosticcenters, many of the things we
used to admit TAS P E's. Maybesome of those can actually be
(21:30):
observed and go home. And thatcan be a growing role of what
emergency medicine can be. Andmany people are expanding beyond
their roles traditionally ofworking in the emergency
department and getting intoother aspects. Dr. Kellerman,
who was a dean at USUS is nowone of the first emergency
medicines who is a CMO of amajor hospital and health
system. We havea bunch of people who are in the
(21:51):
White House, Dr. Rodriguez hasbeen on the COVID-19 response
task force. So I do thinkthere's a lot of light at the
tunnel, there's so many goodthings coming for our specialty,
that what I want everyone totake home from this is take a
deep breath, it's going to beokay, the world is not falling.
And I've really come to theconclusion that life is all
about attitude. And if you lookat social media, it is
(22:12):
exhausting. And it drains ourenergy because people are always
thinking, the world is endingthe specialty is over. That is
completely untrue. We are in areally good place. And I believe
it is. And I keep going back tomy TED lasso, because it's all
about belief is about believingin a bigger purpose and kindness
and knowing that it's going tobe fine and seeing the longer
(22:33):
vision of where we are as aspecialty. And how do I know
this? And why am I sooptimistic. So this past year,
we spent a ridiculous amount oftime doing strategic planning.
And we were asked to take a.wehad a red dot and a blue dot.
And the board was asked to puton one end we said specialty of
what should ASAP advocate forand then the other end
(22:54):
physician. And know that whenASAP started, as we talked about
it was because the specialtydidn't exist. And so ASAPs
purpose was to defend and createa specialty. And much of what we
were doing was focused onspecialty. And so we all put red
dots kind of between that lineof physician and specialty,
where do we think we are today.
(23:15):
And you can see those red dotson the top. But we were
somewhere in the middle, butleaning a little bit more toward
the specialty. And we talkedabout the blue dot, where do we
need to go? What does the futurelook like? And you can see
that's a pretty notable change.
And I will say even in the fiveyears that I've been on the
board, it was very difficult topivot away from specialty care.
But I make the analogy that yes,our primary mission is about
(23:36):
patients. Yes, the primary thingis about specialty, but you have
to put on your own oxygen mask,right when you're on an airplane
before you put on your child'smask, we have to take care of
ourselves. Because ultimately werepresent emergency physicians
and if we are not advocating forthem and having their back,
we're going to lose people thisneeds to be our focus. And this
was a really aha moment I thinkof a strategic pivot, and what
(23:57):
our mission is going to be tosome of the things I'm most
proud of. Over the summer lastyear, we created a term of what
is an emergency medicineresidency, and that many people
are using this term in theirtraining, but it is not
equivalent to physiciantraining. So asepsis position is
that the term resident andresidency training should apply
only to postgraduate training ofphysicians that we have other
(24:20):
programs for pas for nursepractitioners and pharmacists.
But that words matter, we needto start really differentiating
ourselves from many of ourcolleagues of what our training
is. We've really tried to honedown on what is the right form
of supervision. And this hasbeen a huge challenge. But one
of the things that I'm sort ofmost proud of is is let's start
looking at this what is theright amount of supervision? So
(24:40):
we had a taskforce last yearthat was made up of samba for
the PAs and the nursepractitioners and every em
organization and we've goteveryone in a room and said can
we agree on what definitions areand what is the right level of
supervision? And the group cameup with these definitions. That
direct supervision is What I dowith my residence, right, they
tell me about every patient, Ihave to see every patient and I
(25:02):
have to document every patient,indirect supervision as if
someone discusses the care withme. But I don't necessarily see
the patient, but I hear aboutthem. We talk about the
management in real time beforethe patient is discharged. And
that could either be on site, ifyou're physically in the IDI, or
potentially off site, if you'redoing it through telemedicine.
And there was this category ofsort of oversights, where a PA
(25:25):
or NP could decide whichpatients to present that the
emergency physician is availablefor consultation, but only as
needed. And they would notnecessarily know about the
patient in real time. But theywould review the chart after the
patient was discharged. And ASAPreally has grappled with this of
what do we recommend and what isour policy. And so last month,
(25:46):
we reviewed this and wedetermined that we don't believe
oversight is supervision. It isquality review. If you're
looking at a chart after thefact that that doesn't
constitute supervision. And ifwe're really trying to say we
want the highest level of care,we do feel that at least in a
minimum, indirect supervision isappropriate where you're hearing
about the patient, even if it'sjust hey, I've got a lack in
(26:07):
room five, I'm going to sew itup and send them home with after
a tetanus shot. But I have toknow about that patient before
they're discharged. And wetalked about off site really
only being appropriate for ruralemergency departments or
critical access hospitals whereyou couldn't get an emergency
physician. But that offsitesupervision was not appropriate
for urban, suburban or academichospitals.
(26:29):
We launched a campaign on thevalue of emergency physician of
really what is that differencein training, and to really help
with our scope of practicebattles that are at a state
level, and arguing that we agreeon physician led care of team
based care that everyone plays avery important role in emergency
medicine, but that an emergencyphysician needs to be involved
with every care of patients inthe emergency department.
(26:51):
Another big concern people arehaving is the degree of
consolidation in medicine. Wetalked about this a little bit
at dinner last night. But howmany people remember Blockbuster
video? Remember, we used to havea card and you have done Friday
nights and rent videos a littlelike be kind please rewind. So
what what happened? Whathappened to Blockbuster Video?
Apparently, there's oneBlockbuster video that's still
(27:11):
open. Where's the blockbusterthat's open now? Oregon.
Interesting. Okay. Well, inTexas, I'm not even kidding.
They're all now freestandingemergency departments. And what
I used to work on was a formerblockbuster. So what happened to
Blockbuster, right, the worldevolved around it, we went to
Netflix, we went to streaming wewent to Apple TV, that there was
not a need for renting videosanymore. The way things are
(27:34):
evolving in a capitalisticsociety like the United States
is that things are growingbecause that scale works, right?
You have Home Depot has replacedthe mom and pop hardware stores.
Amazon has put Babies R Us outof business. Things are
changing, things areconsolidating, because from a
business perspective that whatwas needed to be realistic to be
(27:55):
relevant to be able to stay inbusiness. And again, a 70% of
your patients don't pay the costof care. How do you keep your
doors open? The only way to dothat is to scale both
horizontally and vertically. Sowhat does that mean? So
horizontal integration is if Ihave one small group that buys
out another small group, or Ihave one hospital that buys
another hospital. And now in thehealth system. Vertical
(28:17):
integration is when you have aemployer who is not just
emergency medicine anymore, butthey buy radiology, they buy
anesthesia, they buy thehospitalist because they can
scale those costs, right?
Instead of having five differentmedical directors and benefit
managers, you have one. So thereis some benefit to that. And
that is the model that hasreally succeeded, if you will,
in the marketplace. And thoseare market forces that are
(28:41):
driving that. Anyone know howmany small groups are left in
emergency medicine that haveover 60,000 patients? It's about
150. They're left in the wholecountry. And so we're seeing
this increase consolidation isnot just for big groups, it's
hospitals and health systems andacademia that are invested
sometimes with private equity,sometimes with venture
(29:02):
capitalism, but getting thatfunding to keep that business
model sustainable. So they don'tbecome blockbuster. But what
does that impact ofconsolidation? How does that
have an effect on our practice?
People are concerned that asthings have become more and more
consolidated, that we have sortof less control of our practices
of what is the impact on oursalaries. So I will tell you,
(29:23):
the group that I used tomoonlight for and do odd with
got bought out by a big group.
And I asked them what haschanged. They actually all make
the same amount of moneyactually, many of them make more
than they used to. They arestaffing has not changed, but
they don't make those decisionsanymore about what is the
staffing in the emergencydepartment. How many patients an
hour Am I seeing? And peoplefeel frustrated by that lack of
(29:44):
control. And we're seeing thatnot only in corporate groups,
but even in academic groups inother health and hospital
systems in the community. Asthings have gotten bigger, we
have less and less control overthose individual decisions. So
the FTC the Fed When TradeCommission has come out and
said, We are concerned that thisis happening across all
spectrums of too muchconsolidation, not just in
(30:05):
healthcare, but in Google andAmazon and Disney, right? All of
these things are bigger isbetter. But is it? We want to
know what the impact is onconsolidation, tell us your
stories. And so ASAP met withthem. And they asked us to put
together a letter. And so wehave until April 15. So if
you're in a group that has beenconsolidated, we want to know,
how has it impacted your salary?
(30:27):
How has it impacted yourautonomy? How has it impacted
your ability to care forpatients, and we're compiling
those results of the FTC canmake stronger guidelines to look
at vertical and horizontalmergers. And just this
yesterday, we passed a newstatement on private equity and
corporate investment inemergency medicine. That says we
are increasingly concerned aboutthe expanding presence of
(30:48):
private equity and corporateinvestment in healthcare, that
we are concerned that this isimpacting our ability to have
autonomy in our practice, andthat this needs increased
scrutiny, and how we reallyreport care and how we take care
of patients and betterunderstanding the impact of cost
of quality and a physicianautonomy. And we're really
calling for more transparency,because that's what it comes
(31:09):
down to is not just who is youremployer, they quote good or
bad, but what are theirbehaviors? Not all private
equity groups are bad. Not allacademic groups are good. We
tend to put people in thesebuckets. But really, we should
ask, what is your contract looklike? Do you have due process
if you were to get fired?
Because you spoke up about nothaving PPE or there was a
patient? Who is risk? Are youallowed to do that? Are you
(31:32):
going to get fired for puttingyour neck out? Do you see what's
billed and collected under yourname, or you have a non compete
clause where if I lose my job, Ican't work in a certain area.
All of those things are areharmful to physicians. And we
have always advocated for thehighest ability practice and
those good behaviors. And so oneway we've changed this year was
to create this checklist. Sothat anyone that exhibits or
(31:54):
sponsors or works with ASAP isasked to fill this out. So you
can scan them with a QR codewhen you walk around the exhibit
hall. And you can see exactlywhat they offer and what they
don't. With the idea being thatif you have increased
transparency, you can decidewhat's best for you. Right? Some
people in this group, they don'tcare about billing transparency,
they could care less what'sbuilt in their name, but they
(32:14):
want a good maternity policy.
Right? Somebody else reallyfeels strongly about due
process, but could care lessabout CME reimbursement. So I
can't tell you what is good andwhat is bad. I can only tell you
what they offer. And you shoulddecide what job works for you.
We've had a number of hugelegislative wins this year. So
in Georgia, we had a lawsuitagainst BlueCross BlueShield.
(32:37):
They have a list of diagnoses,that if you put on your chart,
they would say we're not goingto pay you for that, because
that didn't really need to bethere. So chest pain guy comes
in with chest pain, shortness ofbreath, you work them up, right?
Everything's normal, their heartscores low, they go home, your
diagnosis is noncardiac chestpain. Well, the insurance
company was coming back andsaying, Well, Gillian, that's on
(32:58):
my list of 800 things that arenot an emergency. So that
patient didn't need to be there.
I'm not going to pay for it. Andwe said, well, that's kind of
BS, right? Because we don't knowwhen the patient comes in. If
they have noncardiac, chest painor something else, we should be
looking at their presentation,not on their final diagnosis.
But yet that was the plan thatBlueCross BlueShield. They had a
list of 800 things whichincluded chest pain, asthma,
DKA, vaginal bleeding, it wenton and on of all things, they
(33:22):
didn't consider emergencies. Sowe said, that's fine. We're
going to sue you. How do youlike that. And we want and that
was a big deal of how we applythis now that retrospectively,
they can't use this list ofthings to say that they're not
going to pay for something. InVirginia, they had the same
battle this year, with Medicarenot reimbursing for services, if
it meant a secret list of about500 different diagnoses. And our
(33:43):
position has always been youcan't use a final diagnosis to
determine what is an emergency.
And what is not a nationallevel, we had a huge win this
year. So out of network, which Iwon't go into the details of but
effectively this put another 50to $100,000 in every emergency
medicine physicians pocket inthe civilian side, because it
(34:06):
had this law gone into act, itwould have allowed the insurers
to decide what to pay you. Soessentially, if you are in the
community, you're doing od E andyou see a patient and you say
it's a chest pain, I'm going tocharge $100 Right, the insurance
company was coming back andsaying, We'll give you $5 And
you're like $5 I can't keep mylights on. I can't pay for my
(34:26):
nurses. I can't get my CTscanner. That's ridiculous. And
the insurance company says Takeit or leave it. Here's five
bucks if you want to be out ofnetwork that's on you. But our
in network rate is $5. So yousay okay, well, that kind of
stinks. I guess I'll be out ofnetwork because I can't keep my
lights on for $5. Well, whathappens if you're out of
network? There is no process toadjudicate what is a fair price
(34:48):
when he baseball players in theaudience. I'm not a baseball
player, but I learned a lotabout the MLB. So when they
negotiate their contracts, theycome out and say I think I'm
worth $10 million and the Thebaseball league says no, you're
worth a million. The arbitratordoesn't average them, they have
to pick one or the other of whatthey think they're worth. And so
(35:08):
incentivizes both people to cometo a reasonable offer. So what
we advocated for is, well, let'sdo a baseball style arbitration.
So if I come and I say, I thinkthe price is $100, and the
insurance company says it'sfive, the arbitrator would have
to pick one or the other, notaverage, the two. And if the
insurance comes back withsomething that's so ridiculous,
they're gonna pay us what we'reasking for. And that was the law
(35:31):
that got passed is we're gonnahave this arbitration process,
which was a huge win foremergency medicine. But when it
got implemented into actuallyhow it was going to be carried
out, the devil is always in thedetails. The government said,
we're gonna leave it up to theinsurers to decide what a fair
rate is, well, whatare the insurance companies
going to do? Right, they'realways going to do something
that saves the money. So we suedthe federal government, which is
(35:52):
an awkward position when youwork for the federal government.
But it was a step not me. Andagain, that's the value of Asa
because it gives you coverage,right? So you can advocate for
us as physicians, and much ofwhat that talk was yesterday, it
helps give us a voice that wecan make changes. So we sued,
and we sued across the country.
And we did it with theanesthesiologist and the
radiologists. It was a wellcoordinated effort across the
(36:14):
country in multiple differentstates with the same premise
that we are suing because thisis an unfair process. And
recently, we won in Texas and sothe government is now backing
off and having to come back withwhat is their new rule of how
they're going to pay for healthcare. And most excited as we
pass the Lorna Breen act, formany people who don't know Lorna
(36:34):
Breen, she was an emergencyphysician who took her own life
in the middle of the COVIDpandemic. And she had no history
of mental illness. She was byall accounts healthy, happy
medical director, and tragicallytook her own life. And this is a
topic we need to really startgiving more attention to. We
have stigmatize mental health,we have made it not okay for
(36:56):
people to ask for help. And weare seeing record number of
physician suicides, residentsuicides, that we need to start
advocating for more resourcesfor destigmatizing being able to
ask for help when we're notokay. And we got this passed
into law just a couple of weeksago. So yes, we have a number of
short term challenges. Bring iton. That is what we do. We're
(37:20):
not afraid of challenges. We'vehad challenges our entire
lifespan as a specialty, we weretold by people that we were the
enemy that we would never exist.
And every time we got punched inthe face, we got right back up,
because this is who we are. Andthis is what we do. So are there
going to be some short termchallenges? Yeah, I'm not afraid
of that. We've always had shortterm challenges workforce scope
(37:40):
of practice all theselegislation out of network
billing, we go back to the coreof of who we are and why we got
in this to begin with. And thatwas to help patients. It was to
be there when nobody else isthere at two o'clock in the
morning, to be the bestphysicians we can possibly be to
provide our care for patients.
And about being the mostresilient specialty there is,
(38:02):
there are going to be times weget kicked down. That's okay, we
can get right back up andlearning to really bend with the
wind and not break in the storm.
And so I see a very brightfuture for emergency medicine.
I'm very encouraged by all thethings we just talked about of
ways that ACF is strategicallypivoting to address each and
every one of those issues. Andto look forward. There are going
to be some short term volatilityfor sure there is but long term
(38:23):
goals and where we're going as aspecialty is we're heading in
the right direction and I see avery bright future for our
specialty and I couldn't be moreproud to serve as president of
both this chapter and nationalASAP and I thank you very very
much for your time.
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I’m Jay Shetty host of On Purpose the worlds #1 Mental Health podcast and I’m so grateful you found us. I started this podcast 5 years ago to invite you into conversations and workshops that are designed to help make you happier, healthier and more healed. I believe that when you (yes you) feel seen, heard and understood you’re able to deal with relationship struggles, work challenges and life’s ups and downs with more ease and grace. I interview experts, celebrities, thought leaders and athletes so that we can grow our mindset, build better habits and uncover a side of them we’ve never seen before. New episodes every Monday and Friday. Your support means the world to me and I don’t take it for granted — click the follow button and leave a review to help us spread the love with On Purpose. I can’t wait for you to listen to your first or 500th episode!
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com