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Originally published: Common Sense January/February 2020
As physicians, we all subscribe to the four tenets of medical ethics: autonomy, justice, beneficence, and non-maleficence. These ideals are integral in providing ethical care to all our patients, from the weakest and most vulnerable, to the most astute and medically literate. Our patients deserve these moral characteristics in their physician in order to get the best care possible. But what do physicians deserve?
If we were to apply these factors to ourselves as EM physicians, we’d see a grim trend of unethical practices occurring in our own specialty. Corporate greed, poor educational transparency, loss of autonomy – and the illegitimization of the emergency physician.
Let’s start in chronology from residency. Today’s medical students applying to emergency medicine are already in an ethical dilemma, especially those that are less competitive. The huge flux of for-profit emergency medicine programs offers just about any medical student the opportunity to become an EM physician. In 2009, there were 1,472 spots in the NRMP Match. This year, it’s 2,488 – a rise of more than one thousand spots.1,2 A key player in this massive expansion of programs – for-profit non-physician owned corporate medical groups. As a medical student that cannot match a reputable, non-corporate program, you’re left with the decision of “do I not follow my dream of matching EM?” or “do I match into EM even though it is under the influence of an unethical training model?” The vast majority of non-competitive applicants, based on our match rates, choose the latter – many not knowing that they’re even in a for-profit corporate program.
If this weren’t enough, these programs are undermining simple supply and demand economics. Despite data showing that our EM workforce is reaching a plateau, our specialty has been having a rapidly expanding number of residency positions – the most of any specialty in the house of medicine.3,4 Why? Some theorize this is to cheapen labor, both via implementing residents (underpaid and overworked high-skilled commodities) into a hospital system and also to increase the supply of EM physicians to the point that oversupply leads to lower wages for physicians to the benefit of for-profit entities as they increase their revenue. Ethical Principle #1: Autonomy.
These same entities undermine your education by introducing one-year family medicine fellowships in emergency medicine and PA and NP “residencies” - in a degraded use of the term - that are directly competing with EM resident education in the institutions that host these programs.
As physicians, we all subscribe to the four tenets of medical ethics: autonomy, justice, beneficence, and non-maleficence. These ideals are integral in providing ethical care to all our patients, from the weakest and most vulnerable, to the most astute and medically literate. Our patients deserve these moral characteristics in their physician in order to get the best care possible. But what do physicians deserve?
If we were to apply these factors to ourselves as EM physicians, we’d see a grim trend of unethical practices occurring in our own specialty. Corporate greed, poor educational transparency, loss of autonomy – and the illegitimization of the emergency physician.
Let’s start in chronology from residency. Today’s medical students applying to emergency medicine are already in an ethical dilemma, especially those that are less competitive. The huge flux of for-profit emergency medicine programs offers just about any medical student the opportunity to become an EM physician. In 2009, there were 1,472 spots in the NRMP Match. This year, it’s 2,488 – a rise of more than one thousand spots.1,2 A key player in this massive expansion of programs – for-profit non-physician owned corporate medical groups. As a medical student that cannot match a reputable, non-corporate program, you’re left with the decision of “do I not follow my dream of matching EM?” or “do I match into EM even though it is under the influence of an unethical training model?” The vast majority of non-competitive applicants, based on our match rates, choose the latter – many not knowing that they’re even in a for-profit corporate program.
If this weren’t enough, these programs are undermining simple supply and demand economics. Despite data showing that our EM workforce is reaching a plateau, our specialty has been having a rapidly expanding number of residency positions – the most of any specialty in the house of medicine.3,4 Why? Some theorize this is to cheapen labor, both via implementing residents (underpaid and overworked high-skilled commodities) into a hospital system and also to increase the supply of EM physicians to the point that oversupply leads to lower wages for physicians to the benefit of for-profit entities as they increase their revenue. Ethical Principle #1: Autonomy.
These same entities undermine your education by introducing one-year family medicine fellowships in emergency medicine and PA and NP “residencies” - in a degraded use of the term - that are directly competing with EM resident education in the institutions that host these programs.
And then there is the issue of residency closures. This trend of poorly run, poorly staffed, vaguely structured for-profit corporate systems producing residency programs across the U.S. is being showcased with each residency closure that falls on the back of trainees. After undergoing the difficulties and financial burden of medical school, many residents are in the limbo of unstable residency training. Profits aren’t doing as well as hoped? The corporation pulls out and the most impacted bystanders are residents. If that weren’t enough, residents in the aftermath are treated like well-groomed sheep, having their residency funding auctioned off to the highest bidder.5-8 Ethical Principle #2: Justice.
And next, enter the practice of emergency medicine. Your options at jobs are limited to working for non-physician for-profit corporations with metrics and bottom lines and your due process waived as soon as you sign on, to “medicine” or democratic physician-led groups that may lose their contract to the former in the coming years.9,10 Many of these corporations are also now replacing traditionally EM staffed jobs with midlevel providers, both with the expectation that the few staffed EM physicians will sign charts blindly, and with the understanding that despite significant lapses in education when compared to physicians, these MLPs are much cheaper labor that bring in the same revenue when their charts are signed by an attending physician.11 For many years, our specialty has fought long and hard to establish the importance of being a board certified EM-trained physician. To other physician specialties’ detriment, we did away with the notion that non-EM trained physicians were okay to practice in the ED and thus solidified the EM specialty. The irony, however, is that now we’re okay with subjecting our vulnerable patients to family-trained nurse practitioners with substantially less training than family medicine physicians? Even more, we do so knowing that these same practitioners are fighting actively to replace our profession with bills of independent practice and claims that their care is equivalent to ours.12 Is this not a fallacy? Ethical Principle #3: Beneficence.
And now enter surprise billing: an issue so clearly the fault of corporate medicine greed that has of course, conveniently fallen on the eroding reputation of doctors.13-17 The fallout of which is on the backs of EM physicians – with expectations that our salaries will go down if our government finds ways to further regulate EM reimbursement. Ethical Principle #4: Non-Maleficence.
At the end of the day, whether from a 60,000 foot view or a 6mm view, our specialty has become infected by the parasitic behavior of for-profit corporations. Corporate medicine has infiltrated all aspects of our specialty, from our training programs, to our staffing, to our patient’s care, and even most concerning – they’ve infiltrated our specialty societies. Whether we, as the next generation of EM physicians, recognize and stop this bastardization of our specialty is up to us.
To all the medical students thinking of pursuing emergency medicine, we invite you to choose this as your specialty - to us and many others, the best specialty. But we also caution you to recognize what you’re getting into. If you’re not swayed by what you’re reading, take off the white coat and roll up your sleeves, our generation has a lot of cleaning up to do.
References:
1. https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2013/08/resultsanddata2009.pdf
2. https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2019/04/NRMP-Results-and-Data-2019_04112019_final.pdf
3. https://www.jem-journal.com/article/S0736-4679(15)00952-X/abstract
4. https://journals.lww.com/em-news/FullText/2019/02000/Viewpoint__Emergency_Medicine_Doesn_t_Need_More.18.aspx
5. https://www.crainscleveland.com/article/20170209/NEWS/170209779/summa-emergency-medicine-residency-loses-accreditation-health-system
6. https://www.inquirer.com/business/health/hahnemann-residency-progam-sale-cms-appeal-20190912.html
7. https://acgme.org/Newsroom/Newsroom-Details/ArticleID/9572/Ohio-Valley-Medical-Center-Closure
8. https://www.theintelligencer.net/news/top-headlines/2019/10/three-medical-residency-programs-end-with-ovmc-closure/
9. https://www.annemergmed.com/article/S0196-0644(17)30196-8/fulltext
10. https://annals.org/aim/article-abstract/2720155/private-equity-acquisition-physician-practices
11. https://tincture.io/just-sign-the-chart-everybody-is-doing-it-8043936c9a83
12. https://www.aanp.org/advocacy/advocacy-resource/position-statements/quality-of-nurse-practitioner-practice
13. https://hbr.org/2019/10/the-role-of-private-equity-in-driving-up-health-care-prices
14. https://www.washingtonpost.com/opinions/2019/10/18/elizabeth-warren-takes-wall-streets-role-our-surging-medical-bills/
15. https://www.nytimes.com/2019/09/13/upshot/surprise-billing-laws-ad-spending-doctor-patient-unity.html
16. https://www.forbes.com/sites/theapothecary/2019/09/26/how-arbitration-for-surprise-medical-bills-leads-to-runaway-costs-higher-premiums/#3e38d90e4442
17. https://www.forbes.com/sites/theapothecary/2019/06/17/a-new-bipartisan-bill-could-transform-the-way-we-pay-for-hospital-care/#49e9241522ee
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