Thank You Sir, May I Have More (Bulls**t)?

When I was a child in the ‘70’s, there was a very popular series on the air called, “Emergency!”. It revolved around Gage and DeSoto, two paramedics associated with the fictional Fire Station 51 and Rampart General Hospital ER. In the ER was Dr. Brackett the ER physician, Dixie McCall, the head nurse, and Dr. Early, a neurosurgeon(I didn’t know enough then to question why an NS was in the ER regularly…). It was that show that began my interest in the field of emergency medicine. Initially, I wanted to be a paramedic; however, I was impressed with Dixie McCall and decided I would be an ER nurse and eventually entered college as a pre-nursing major. Over the years and after obtaining more experience, I subsequently decided I craved the expertise and knowledge of a physician. I earnestly desired the ultimate responsibility of determining the care and/or management of patients. I had a strong sense that I would be good at making decisions in a crisis. I was right.

The moment I set foot in an emergency department, I knew I belonged there. That environment was a perfect fit–I am at my best when I have to react swiftly and with clarity. The challenge of being prepared to handle whatever entered those ER doors was titillating. 25 years later that excitement has not dissipated one iota. I thought I would never leave….until I did. It became an environment in which I no longer desired to practice and decided to take a respite.

When I trained, I learned about the history of how acute care medicine came to be. I’m extremely proud of that history because the founders of this specialty recognized that the public needed emergentologists. The changes they instituted, which included pre-hospital care, changed the course of medicine forever. Exceptional standards for emergency medicine were established and the quality of care improved. As a result, many lives have been significantly impacted–in a positive way. Being part of this family was an honor…then corporate medicine entered the picture.

I barely recognize my specialty at times. The priority of treating the sickest patients first has transitioned to “moving the meat”, a practice that inherently does not favor the sickest, but the least ill. This inevitably delays care to those who most need it. Waiting room times, length of stays, time to admission and other metrics meant to improve reimbursement has infiltrated, much like cockroaches, what was a wonderful clinical mecca of acute medicine. Patient education is compromised and patients are treated as commodities. Patient satisfaction scores have become the litmus test of one’s clinical performance. Yep, a popularity contest trumps the actual practice of medicine. And the art of acute care medicine is now being taken out of the hands of the medical experts and handed over to non-physician practitioners(NPPs) by corporate whoremongers. ER physicians are being forced to supervise and teach their replacements or become unemployed. The ones to whom we were expected to hand the torch, medical students and residents, are being pushed aside and their education compromised…all in the interest of supposedly saving money. I submit there is also one other less discussed reason. Physicians are notorious for refusing to take orders from corporate management, especially if it places patients at risk. You know–the conscientious docs labeled as “disruptive”. We tend to be passive creatures, but not when it comes to this–we are fervent patient advocates. We take the heat for being so…if we have to. Unfortunately for the C-suite, besides our oath, we are supported by the bylaws of every hospital which places the ultimate management decisions in the hands of the treating PHYSICIAN. They can’t have that, so they use practitioners who are not only cheaper, but less likely to resist the pressure placed on them because they simply do not possess the same authority to oppose corporate leadership.

Nevertheless, the transition is happening. Physicians are fearful of losing their jobs, not understanding that the stage is being set for them to lose their jobs anyway. So they assist in the transition. The barely concealed actions by so-called academic institutions to replace physicians and/or minimize the significance of our roles on the healthcare team is reprehensible. The information page at the top of my commentary was recently posted by Indiana University Health(and abruptly removed from their website). While thousands of unmatched medical school graduates(and potential ER docs) sit on the shelf collecting dust because there are not enough residencies for them, IUH has begun an ER program for non-physician practitioners who have no requirement to complete the steps I did to become an expert in emergency medicine. There is no presumption on my part that the leaders in the Department of Emergency Medicine at IU initiated this process because I’m not convinced they did. I do believe they are being forced to sanction and assist in its formation based on the notice from IUH(see below) regarding other “fellowships” for the NPPs. There is no way in hell you can convince me that the ER residents(or most core attendings) in this program are in support of permitting non-physicians to participate in their ACGME mandated residency. If they are, I would be mortified. I question whether ACGME is even aware that IU is enabling this very questionable activity. In my opinion, the idea to develop “fellowships”(professional appropriation at its best) is a corporate one.

I am incensed and offended. I’ve been lecturing middle school, high school and college students on the value of education for over 30 years. Because education matters. Like other physicians, I worked my a** off to achieve what I have so I could bring the best that I have to my patients because if not for these selfless patients, I would not be the physician that I am. I also would not be the physician that I am had I not completed the standardized preparation and training that is mandatory to become a physician and that has worked, under the Johns Hopkins model, for 100+ years in America. Yet, an “academic center” such as IU has the audacity to not only promote, but brag that they are training NPPs to become “specialists” in Emergency Medicine, “specialists” who can then go on to “independent” practice states, work in an ER and tell patients they “specialize” in emergency medicine because they completed a “fellowship”. The potential to deceive the public is enormous. Eventually, because of programs like IU’s, my EM residency certificate won’t mean s**t anymore. My board certification, which required me to take TWO all day exams, one written and one oral, a year apart…won’t mean s**t anymore. Because IU has found yet another truncated pathway(besides legislators) to enable NPPs to become emergency medicine “specialists” rather than effectuate the seven years that was necessary for me to achieve the same. This does not only apply to EM, but also the other specialties in this link to IU’s “APP fellowships”( Imagine that…a fellowship without completing medical school or a residency. So much for valuing physicians and medical education. Shame on IU. I sincerely hope that as academic programs continue to develop these ER “residencies” and “fellowships” for NPPs(IU is not alone), all the while ignoring unmatched medical graduates, emergency medicine’s umbrella organizations and societies, including the American College of Emergency Physicians(ACEP) and American Academy of Emergency Medicine(AAEM), take note and address this corruption of our specialty accordingly.

Medical students applying for residency, take heed.??

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