An Incestuous Affair–The CPOM and ACEP

This past weekend I watched “Bad Sport”, a documentary series on Netflix regarding corruption in various sports….motivated by greed. It wasn’t that the perpetrators weren’t rich, they had plenty of money. However, it wasn’t enough, they wanted more. So much so that it led to them violating the purity of these athletic events which they claimed to love so much. In other words, their love of the game did not override their love of money. What I found even more distressing was that in some cases they used the athletes themselves to perform their dirty deeds. The various sporting events included basketball, auto racing, soccer, ice skating, etc. By far, the worst episode was the “Horse Hitman” in which a former stableboy known as the “Sandman” was hired by wealthy owners and/or their trainers to kill show horses for the insurance money. Most of the time he killed them by electrocution. While watching this series, I began to correlate some of the behaviors I saw in the show with what is occurring in my beloved specialty of emergency medicine(EM). One difference is that death by electrocution is much quicker and humane than what is occurring in EM which is the slow, very painful death…of my profession.

Nearly thirty years ago, James Keaney, MD wrote the iconic book, “The Rape of Emergency Medicine” under the moniker, “The Phoenix”. It described how the corporate practice of medicine(CPOM) not only exploited emergency medicine physicians but also engaged in questionable and unethical business practices that increased profits. But corporate medicine did not achieve this alone, it was assisted by predatory emergency physicians(EPs), many of whom were members of the only emergency medicine physician organization that existed at the time, the American College of Emergency Medicine(ACEP). Dr. Keaney and others were members of ACEP as well; however, they wanted to preserve the history of emergency medicine(EM) and its beginnings as a socially conscious specialty that placed patients first. In addition, they had a desire to protect the specialty of EM and the physicians within it from the mercenary business of medicine. Subsequently, a conflict arose between EM physicians on opposite sides of the aisle: those who sanctioned the CPOM and those who did not. The physicians from the latter group broke off and became the American Academy of Emergency Physicians(AAEM). The aforementioned division remains today.

When I began my career as a resident in emergency medicine, I was bright-eyed, bushy-tailed and ready to rumble. I completed an excellent EM program in which my attendings and department leaders were committed to my education. I was advised that ABEM docs were the gold standard and could demand premium pay. My particular residency was also a pipeline to ACEP by way of the Emergency Medicine Residents’ Association(EMRA). Membership in ACEP was pushed–I knew nothing of AAEM, the history of its beginnings or the division within ACEP. I remained a member of ACEP for 23 years. For the record, I sincerely appreciate ACEP’s significant contribution to the growth of the specialty of emergency medicine. The introduction of point of care ultrasound, ensuring compensation for EM docs performing duties outside of the ER and other fights regarding our reimbursement, their enthusiastic support and promotion of the development of various fellowships beyond EM and most recently, their vigorous activity regarding the surprise billing issue. There is no question that ACEP was very instrumental in expanding the specialty of emergency medicine. They just haven’t provided much protection of the specialty, in my opinion.

Single democratic groups(SDGs) still existed when I entered the world of emergency medicine practice. Many were just as predatory as the contract medical groups(CMGs) are today. Nevertheless, my clinical expertise was appreciated and supported. As EHRs were introduced and CMGs took over our practices, metrics became the name of the game and suddenly patient opinions and numbers were more important than my clinical performance. The change in the EM landscape was considerable, so much so that I made a decision to leave full-time medicine in 2008 and practice locum tenens where I could have some control over where and for whom I worked. That introduced me to more avaricious practices which necessitated me aggressively advocating not only for my patients, but for myself. I did not make any friends in the corporate world who wanted me gone. Yet, I was never officially terminated. Instead, EM colleagues were used as pawns to remove me from the schedule when I would not conform to what I considered to be immoral clinical practices, aka the CPOM. They questioned nothing, just did what they were instructed to do. And they most certainly didn’t advocate for me, despite my being a very good doc and having an impeccable record. The irony is that each and every time I was hired, two questions arose asking if was I board certified and if I ever had any lawsuits. My answer was always “yes’ and “no”, respectively. Then these rapacious entities known as CMGs would then proceed to place me in situations in which I could suffer legal ramifications had I practiced the way they expected; thereby ruining my perfect record. I was not about to let that happen. They mistakenly thought my license belonged to them. They were reminded that that was not the case. What I had less control over was the forced supervision of non-physician practitioners(NPPs) who were hired by the CMGs without my input. To protect my license, I worked hours after my shift, poring over NPP charts to make sure nothing critical was missed. If I had concerns, I would follow up on the patients myself. In order to get paid for the overtime, one of the CMGs required me to write an email to the corporate office(which was in another state) explaining why I worked overtime. Then some non-medical jackoff would arbitrarily decide if I deserved to get paid, even if that over time included actual clinical care. Since the nature of EM almost always resulted in me working over time, I gave up. I had no intention of writing that many emails–I knew this nonsense was designed to discourage me from requesting pay. They won that battle. The most difficult part of each battle is that I was fighting the battle on my own the majority of the time. I was fortunate enough to have two ED directors during my career who provided me immeasurable support and to them I will forever be grateful. Most ED directors are at the mercy of the CMGs and have no real power. They are figureheads.

I eventually came to the realization that my true empowerment was in my independence and marketability. I had to maintain a clean record and obtain great references. My work had to be above reproach and my practice record clean. Even if some vengeful f**k tried to spin the story to ruin my reputation, they couldn’t. I never had a peer review or risk management case. I dotted all my i’s and crossed all my t’s. I made sure it was known if anything followed me negatively such that it would affect my ability to be hired, there would be action taken. Malicious and vindictive behavior I would not tolerate. The last decision I made to gain back almost complete control was to cease supervising NPPs. I did not trust the lax vetting that the CMGs considered sufficient. If I did not have input into the hiring of people working under my license, then they could not work under my license. Period. That severely limited my prospects. Didn’t matter, I still found jobs that were NPP-free and moved on.

It makes me sick knowing that there are members of the ACEP board who support and promote the CPOM in EM. They simply have no issue with it, it’s just business after all. They disregard the hundreds of EM docs who are terminated without due process for advocating for patients and other physicians. All physicians have a moral and professional responsibility to protect the public and these docs did what was right. The CPOM is the complete antithesis of our oath and these business people could give a s**t about the public or their health and safety. Unfortunately for EM, some of those board members in ACEP have also lost their moral compass and pledged their allegiance to corporate medicine by their inactions–their words implying the opposite don’t mean s**t. They don’t fight for our due process based on some vague weak a** excuse that it is “too risky”. They don’t care that EM residents have difficulty finding jobs thanks to a glut they did little to prevent, they stand idly by while the CPOM’s standard of hiring cheaper and less qualified labor to replace EM physicians en masse continues, thereby worsening the employment prospects of graduating EM residents even more…Motivated by abject greed and rewarded for a job well done by the Cartel and the Pimps(https://authenticmedicine.com/2021/08/pimps-and-hos-wherever-rosemary-goes/) with bonuses and promotions to prestigious executive roles. 

It wasn’t until I joined a FB group in 2016, EM Docs, that my eyes were opened about ACEP and the history of the famous division. ACEP leaders showed me who they were in that forum. With over 20,000 members, there were several leaders of ACEP and AAEM in the group. There were many EM physicians with the same concerns I had about forced supervision of NPPs, docs being terminated without due process or worse, being maligned by former employers to prevent them from being hired anywhere else and effectively ending their careers. I was genuinely shocked when ACEP leaders remained mum about these issues which directly affected individual emergency physicians on the frontlines. ACEP leaders’ hesitancy to become involved or even comment on what were obvious violations of due process irritated me. I was so naive as a resident. I never paid attention to ACEP’s COI’s when I had attended a few of the ACEP annual conferences. I was one of those physicians who went to the booths of all the CMGs and Locum Tenens companies present. ACEP made it so easy for them to prey and I was completely oblivious. Blind as a bat. How is allowing these predacious corporations to set up house at those conventions acceptable? Why provide an opportunity for the CMGs who abuse EPs to pounce? I waited for the comments in the EM Docs forum explaining this disconnect. Something….anything. It was for naught. I got crickets. Regardless of what ACEP has done for the specialty of EM, for me, it’s what they have not done for EM docs individually that disheartens me the most. After the ACEP board provided a grant for the Emergency Nurse Practitioner certification exam, that was the last straw and I chose not to renew my membership. How tone deaf could they be? If they had the funds available, why not redirect that money where it could benefit a medical student, EM resident or unmatched graduate? To date, I have never received an answer, despite writing and asking the then president of ACEP in 2018. My stupidity was in believing that an organization that has been in bed with the CPOM for 30 years would change its ways. Nope. The rape of our specialty continues…..

During the TakeEMBack Summit at the end of September, I had the pleasure of presenting the Phoenix Award to Dr. James Keaney. The Phoenix Award is presented to physicians who speak out despite fear of retaliation. Dr. Keaney made a comment that resonated with me. I paraphrase, “…ACEP is not going to be changed. I think it is totally illusionistic to think for one second you are going to get to the power behind the throne within ACEP. The matrimony between the contract management groups and the leadership of ACEP is simply…let no man put asunder. It’s not going to happen.”

BELIEVE HIM.

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