#MedicalSchoolMatters

Workforce - the people engaged in or available for work, either in a country or area or in a particular company or industry.

ACEP passed a resolution at the ACEP19 this past October that we are “physicians”, not “providers”. This brings up a terminology issue for “midlevel providers”, “physician extenders”, or “APP”. Interestingly, Centers for Medicare & Medicaid Services (CMS) already has an all-encompassing title they use - Non-Physician Provider (NPP). We can adopt this terminology, as this clarifies that we are the physician and the other providers are non-physician. This is a self-defining term that is already in use by the US government/CMS, and as such, I have adopted it for our purposes.

I am new to workforce issues, with recent cause to become involved. When I went to the Section meeting at ACEP19 in October, I expected to be part a huge group of members given all of the changes starting to affect the emergency physician workforce. Then, to my surprise, there was talk at the meeting about dissolving the Section due to lack of membership. Wow! Seriously, this could be one of the single MOST important ACEP sections right now!

To explain why I feel so strongly about this, here is my story. I am an EM residency trained, EM board certified emergency physician who completed an EM residency in 2000. I love emergency medicine and think it is the best specialty ever. I practiced full-time, until my only daughter was born when I was 41- and, well, I wanted to be a mom, too. I moved to part-time status when she was in preschool and have enjoyed being a doctor-mom since then.

In any case, I have worked since 2001 at a large four-hospital system in Shreveport, Louisiana, other than a brief stint with a competitor hospital to help them start a Pediatric ED. We had a great mix of doctors, a wonderful nursing staff, and we thought a pretty good relationship with administration …until we were blindsided last year when they brought in a contract management group to take over our contract. Part of the new process they planned on implementing was to bring on NPPs. The first cut to our workforce was their plan to release all of the part-time ED docs. There are six of us, 3 doctor-moms, and some military physicians. Out. The other part of the plan was to decrease the hours of the remaining doctors to make room for the NPPs. Oh yes, and an hourly pay cut for the “surviving” emergency physicians. The contract management group (CMG) is phasing in the NPPs over this year, and the process has had its challenges.

When this happened in April 2019, I was dumbfounded - how could a doctor be replaced with a non-doctor? It is all about the money. My former EM residency advisor, who is now in an administrative position for the CMG, told me “It’s just business”. However, there are many problems with this business model, and I believe that, in the end, it will be more costly for the patients and the system … and that patient care will suffer.

First off, my bias is that I do not believe that NPPs should be giving unsupervised care in emergency departments. I can see some benefit in a clinic setting or urgent care, when working as a team with a physician leader, but not independently in the ED. I have heard from a former ACEP president who was in charge of callbacks for his shop, and he had to call back many patients - missed appendicitis, missed ovarian torsion, to name a few. True, incorrect diagnoses could happen with physicians, but we have more education and experience that this should not happen as frequently as non-physician providers.

We need to define our EM workforce, because if we do not, it will be defined for us. Our jobs are at risk, along with patient lives. This is BIG right now. Many states have already approved for NPs to have independent practice, under the guise of helping rural and underserved areas. However, it seems they do not want the rural jobs - they want our jobs in the city. When I was displaced last year, I went to work in two rural EDs near my home - and I LOVE it. I get to do patient care and education, am not as rushed to move the patients, and can actually listen to patients’ stories. I have met some fabulous family medicine physicians working in these rural EDs, providing great care to their communities.

During our Section meeting in October, Dr. Carlos Camargo gave us a preview on his latest research on the US EM workforce. He presented the latest information from the ongoing NEDI-USA project, which has information about all US EDs; he shared results from the 2019 emergency physician study, an update of his 2009 publication in Annals of EM; and he presented the latest numbers on NPPs in US emergency care. The presentation had some staggering numbers about the lack of rural ED physicians in the central part of the country. Dr Camargo and his colleagues predict a worsening shortage when these few physicians retire in the next few years. I found the presentation really eye-opening, especially given my recent experiences. My story is not a fluke! On the contrary, there probably are many others like me. I have included his updated report in our newsletter. (link)

What can our EM Workforce Section do to help preserve emergency physician practice and optimize patient care and protection? First, we need to all get on-board and acknowledge that this is a problem we need to fix, and that we can (and should) regain control of this problem. We need more research and discussion to explore this important issue. The ACEP NP/PA Task Force is working on this as well, and there is the proposal to study this for 2 years. I would like to try to get our group active and join with other physician groups in discussing this issue.

We can petition for insurance companies to have the same malpractice rates for the same jobs. If a non-physician is doing the same job as a physician and not signing out patients, then their malpractice insurance should be at the same level due to having the same risk - even more risk, actually. Doctors do not need to be held liable for someone they may not have seen because the NPP did not discuss the patient with them or they did not have time to in a very busy ED. If no physician was involved, then the provider who saw the patient and provided the care needs to be on the line for any malpractice events, and limits of liability need to be the same as the physician. If no physician was involved, then the physician should not be sued. Period.

A proposal presented at our Section meeting could help define our ED workforce in the community. We, as a Section, could draw up certain guidelines for a hospital to have its ED “ACEP Certified”. They would work toward the best possible tier, currently like the levels of accreditation for Geriatric EM. We could define policies/guidelines as far as MD/NPP staffing and present these recommendations onward. We could have public service ads to encourage patients to look for the “Gold, Level 1 Accredited ED” near them.

We also need to work on finding physicians to work in rural EDs since the future looks bleak, especially in the central part of the country. We could encourage some of our physicians to look at rural medicine as a great option for a job - that you do not need to be stuck on the circuit “moving the meat”, but actually enjoy a different pace and interaction with patients. It is a great choice to start out a career or transition to retirement. We need to market this option more to other ED docs. The current rural docs are already dealing with some NPP encroachment on their jobs - I have talked to some of them and I get it.

I went back and read some of the EM Workforce Section newsletters to prepare me for the newsletter editor job. I read the posts on engagED for our Section. One of the largest threads was on “What is the purpose of our Section?” It seems that this section was originally defining EM board certification and legacy physicians among other things. The original goals seem to have been met - but now there are serious workforce issues that will affect our jobs and the future jobs of our younger generation of EM docs. This section was able to successfully define the workforce at that time - and win an award! We can take this past strength and build on it for the fight to save our workforce future. On that note, we can start a campaign with other physician groups for #MedicalSchoolMatters, letting patients know their rights to see a physician and that all clinicians in the ED are NOT the same…. We are not providers. We are physicians.

In closing, this has been more of an introductory newsletter to try to get our Section going again. We have a lot to do, and it may seem daunting, or even impossible. However, I believe we CAN take back some of this and direct changes going forward.

I would love for more newsletter article writers to weigh in on this. We would welcome positive stories about your job and ideas on how to proceed and grow our section. Send me your thoughts at ddfletcher@mindspring.com. I am excited to see what we can accomplish.

Deborah Fletcher, MD, FACEP, FAAEM