What should ACEP be doing, that they're not?

[Birdstrike]

A lot of people are frustrated with ACEP and feel there's more they could do to make the average pit doc's life and career, better. The temptation is to assume they have lots of power you and I don't. Are there concrete actions they could take or are they stuck beholden to administrators, CMGs and government mandates, just like the rest of us?

What are some concrete actions ACEP would take to make things better for EM doctors, if you were President of ACEP?

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[RustedFox]

Policy that ACEP positions cannot be held by people taking even one dime of non-clinical time money from the CMGs.

This falls under the simple idea of conflict of interest, but apparently the children at ACEP think that this elementary principle somehow doesn't apply to them.

 

[docB]

I think ACEP and the CMGs are too closely aligned. This was the impetus for AAEM. It also means we have to be realistic in what we can expect from ACEP. For example asking ACEP to battle the CMGs and gett us back to SDGs is just not going to happen. That said I'd like to see ACEP work where they're goals overlap with the CMGs, at least for now.

One area where ACEP and the CMGs should agree is in fighting metric creep and "customer satisfaction." Both of these problems hurt real quality emergency medicine and neither ACEP (members or leadership) or the CMGs like them. I was in a typical group meeting last year where we were given 17 new metrics to "focus on." It was MIPS, a bunch of chest pain, sepsis and stroke metrics and some others. These metrics cause demonstrable harm to patients, waste resources, cause physician fatigue and lead to dissatisfaction and burn out. They are mathematically capricious and generally ill conceived.

I'd love to see ACEP fight against these with a full scale PR and political campaigns. I have a slogan, "If your loved one is dying do you want their Emergency Physician documenting high blood pressure follow up." (MIPS 2020 Measure #317)

 

[GeneralVeers]

All leadership positions should involve physicians who have worked at least 1 year full-time within the last 3 years prior.

As to metrics, the CMGs don't care. They want contracts, contracts, contracts, and will promise hospital leadership the universe as far as metrics go if they maintain their contracts. Envision, Teamhealth, etc. don't care one bit about doctor burnout, excess work, or patient harm. It's all about satisfying their customers (the hospitals) so that they can return maximum profit to their shareholders. We always make the mistake thinking that patients are our customers, when in fact the CMGs only care about the hospitals.

 

[bravotwozero]

A lot of people are frustrated with ACEP and feel there's more they could do to make the average pit doc's life and career, better. The temptation is to assume they have lots of power you and I don't. Are there concrete actions they could take or are they stuck beholden to administrators, CMGs and government mandates, just like the rest of us?

What are some concrete actions ACEP would take to make things better for EM doctors, if you were President of ACEP?

It's one thing to be an advocacy organization for a profession, and not to do much to successfully advocate for it, because reasons. It's entirely another to work to actively undermine the very profession the organization is supposed to advocate for. What do I mean by this? ACEP supporting 'rural NP training programs'. Why is any of that necessary? Is there a shortage of diploma mills? The least you can do is not pour gasoline on top of the raging dumpster fire...

Is it asking too much? I don't think so

Until and unless they stop these kind of antics, ACEP is making the case for themselves to be abolished, and I will continue calling for them to be torched. From an EP's standpoint, they are target number one.

 

[RustedFox]

+++ BEGIN SARCASM FONT +++


You guys are getting it all wrong.
If you just LISTENED to what the ACEP president said in his interviews: they have two very EXCITING think tanks to *study* the most important issues: future pandemics and D-I-V-E-R-S-I-T-Y.


+++ END SARCASM FONT +++

 

[RustedFox]

It's one thing to be an advocacy organization for a profession, and not to do much to successfully advocate for it, because reasons. It's entirely another to work to actively undermine the very profession the organization is supposed to advocate for. What do I mean by this? ACEP supporting 'rural NP training programs'. Why is any of that necessary? Is there a shortage of diploma mills? The least you can do is not pour gasoline on top of the raging dumpster fire...

Is it asking too much? I don't think so

Until and unless they stop these kind of antics, ACEP is making the case for themselves to be abolished, and I will continue calling for them to be torched. From an EP's standpoint, they are target number one.

I love your answer.
It can be distilled to: "ACEP needs to stop doing what they're doing altogether, so we can be better off."

Related: ACEP needs "think tanks" to solve the problems that they themselves created. Hmm. hmm. hmmmmm.

 

[docB]

All leadership positions should involve physicians who have worked at least 1 year full-time within the last 3 years prior.

As to metrics, the CMGs don't care. They want contracts, contracts, contracts, and will promise hospital leadership the universe as far as metrics go if they maintain their contracts. Envision, Teamhealth, etc. don't care one bit about doctor burnout, excess work, or patient harm. It's all about satisfying their customers (the hospitals) so that they can return maximum profit to their shareholders. We always make the mistake thinking that patients are our customers, when in fact the CMGs only care about the hospitals.

Agreed, but I don't think the CMGs like the metrics. They want to work us like rented mules and toss the husks afterward. But when I'm checking boxes and doing HEART scores I'm not making them money. They want me moving meat like a conveyer belt without a pause. I'm not saying they dislike metrics for a good reason or the same reason we do. I'm saying we both hate the same thing for different reasons so we may as well fight together. And that was the question, What can ACEP, i.e. the CMG's lobbying collective, reasonably be expected to do for the pit docs?

And to clarify, I don't view MIPS, satisfaction or whatever as being a money maker. Any "bonus" anyone gets on those was just holdbacks that are being redistributed. And for big CMGs it will be a wash across their contracts with some sites getting money, some losing out and most floundering along in the middle. They'd rather not waste time training us or yelling at us about it when we could be busting out another widget.

 

[The Knife & Gun Club]

I would like to see a consensus statement from ACEP recommending more robust program accreditation requirements to ACGME.

My ideas:
100 intubations
(75 was found to be the number needed to reach 90% success rate by avg EM resident, so at 100, almost all should be competent How many intubations does it take to become competent?)

200 Adult Medical Resuscitations

50 Adult Trauma resuscitations

50 Pediatric medical/trauma resuscitations

50 CVCs

Volume must be 10,000 pts/yr/resident, of patients seen in the resident areas. For example a hospital with a 60,000 per year volume but only sees 40,000 in the resident area (not fast track or triage/dc) can have 4 residents.

Trauma must be completed at a level 1 or 2 trauma center.

And most importantly, simulated procedures for airways, resus, chest tubes, and deliveries don’t count.

If you cant figure it out, your program loses accreditation or elects to close down. And if HCA/CMGs insists on using residents as cheap labor and destroying the market, let’s at least make them train the new docs adequately.

 

[southerndoc]

Are you suggesting total residents or per year? In other words, in the numbers you quoted, would that be 4 residents total out of all 3 years or 4 residents per year (total of 12)?

 

[The Knife & Gun Club]

Are you suggesting total residents or per year? In other words, in the numbers you quoted, would that be 4 residents total out of all 3 years or 4 residents per year (total of 12)?

No no per class, to be clear.

So a shop that sees 40,000 real patients gets 12 residents.

Total would be unreasonable IMO.

 

[Rekt]

I would like to see a consensus statement from ACEP recommending more robust program accreditation requirements to ACGME.

My ideas:
100 intubations
(75 was found to be the number needed to reach 90% success rate by avg EM resident, so at 100, almost all should be competent How many intubations does it take to become competent?)

200 Adult Medical Resuscitations

50 Adult Trauma resuscitations

50 Pediatric medical/trauma resuscitations

50 CVCs

Volume must be 10,000 pts/yr/resident, of patients seen in the resident areas. For example a hospital with a 60,000 per year volume but only sees 40,000 in the resident area (not fast track or triage/dc) can have 4 residents.

Trauma must be completed at a level 1 or 2 trauma center.

And most importantly, simulated procedures for airways, resus, chest tubes, and deliveries don’t count.

If you cant figure it out, your program loses accreditation or elects to close down. And if HCA/CMGs insists on using residents as cheap labor and destroying the market, let’s at least make them train the new docs adequately.

I think this is reasonable.

-I'd add single department for volume. A lot of places add their volume together from multiple sites to make themselves look better.
-This alone would cut a bunch of spots and straight cut out some residencies.
-I'd increase it to 125 tubes and say at least 75 need to be ED intubations.
-60 CVLs, ED or ICU only. No SIM.
-Resus needs more clear definitions. Some people log anything for them.

No no per class, to be clear.

So a shop that sees 40,000 real patients gets 12 residents.

Total would be unreasonable IMO.

Minimum ACGME requirement is 6 residents per class for EM (along with at least seeing 30k/pts a year). So they'd either have to change it or a decent amount of programs are getting axed (which I'm all for). I don't think any place under 50k a year, which is probably low itself even, has any business being a residency.

 

[Restart13]

Agreed with the above: ACEP needs to endorse new *standard EM residency requirements*. This should be accompanied by an immediate freeze to any and all new ED residencies and a review that looks at phasing out a certain percent of existing residency spots.

 

[Arcan57]

What seems to be being missed in the "pile on ACEP" rhetoric is that like any good villain, ACEP views itself as the hero. Someone suggested that ACEP should be philosophically opposed to metrics, and someone else amplified that by saying CMGs don't want metrics either. Those are jaw-droppingly false statements. Ready for a truth bomb? Metrics are how institutions measure quality. Healthcare as a system is about delivering the most quality for the least money, so to say they don't care about metrics is to suggest that they're willing to ignore half the game. CMGs take over contracts based on their metric improvements on previous contracts. Literally everything a CMG needs to keep a contract has a metric attached (door to doc, % LWBS, serious safety events (SSEs), provider to discharge). Hell, if you're a director there's even a metric for how much the C-suite likes you and your CMG (net promoter score). So remember next time you're trying to get some BS unachievable goal changed, metrics=quality. Quality is an unconditional good (as long as you're not the one paying extra for it), therefore metrics=good. Any argument against metrics that doesn't forcefully severe its link with quality is an automatic non-starter.

And from an ACEP standpoint, if I were the ACEP president I'd be straight up crowing that as a NATION we had some positive movement in the metrics. A 1% drop in LWBS (even if the "seen" is just an NP pushing a button next to the triage nurse) is thousands of Americans that had improved access to emergency care. A 15 min reduction in door-to-provider time is an improvement of 100s of thousands of hours that the sick and injured had to wait to be evaluated. In terms of new residencies, its "growing the field" and "meeting underserved rural America's need for quality emergency care". Additionally, a lot of those new residents are going to become ACEP members which means more $$$ and more power.

It's going to be years before there's any significant pressure on ACEP about these issues from stakeholders they actually care about and what you're hearing now (adaptability, telehealth, partnerships, changing models of care) is going to be what you'll hear then. They're working on finding the message that resonates in a way that to oppose it automatically makes you look childish and churlish. You'll see more job fairs and ACEP will probably provide some forum where predatory groups with crap contracts can more easily reach out to ACEP members desperate for jobs on a nationwide level. I could envision a world where ACEP starts muscling into the recruiter game by adding a more robust clearinghouse especially if it's more transparent than "Southern city close to destination cities with competitive pay".

 

[RustedFox]

Arcan:

I'd be inclined to agree if the metrics actually measured things that matter; like outcomes (resuscitations successful, admissions avoided, bounceback rates, etc) but they more often than not fail to do the very thing they set out to do.

Measuring how "quickly" we get to a bad outcome is the opposite of quality.

 

[EctopicFetus]

They need to limit residents. One option is to move to an all 4 year training program. Will blast the current programs and fewer people will view it as desirable.

Agreed on caps on residents. I like the 10k per resident per year. Also no more than 1-2 total rotations outside of your hospital. This will prevent these tiny dumpster hospitals from having a residency.

If you have a PICU and a trauma center you are probably a real hospital. You should have one of these 2. I haven't given this a ton of thought but IMO find a 3rd "hard" thing to get, not some nonsense badge like a stroke venter or CP center and then say you have to have 2 out of 3 of these.

Its insane what is going on right now with the explosion of these trash ass residencies.

 

[bravotwozero]

What seems to be being missed in the "pile on ACEP" rhetoric is that like any good villain, ACEP views itself as the hero.

They can view themselves as the king of England, or the tooth fairy. Doesn't change anything, like putting lipstick on a pig. Still the easiest target for unemployed grads and EPs, as opposed to CMGs, or CMS.

We don't need no water let the mf'ers burn!

 

[Arcan57]

Arcan:

I'd be inclined to agree if the metrics actually measured things that matter; like outcomes (resuscitations successful, admissions avoided, bounceback rates, etc) but they more often than not fail to do the very thing they set out to do.

Measuring how "quickly" we get to a bad outcome is the opposite of quality.

Yeah, but we don't pick metrics based on how useful they are. We pick measurements based on how easy they are to obtain. Then we pretend like metric we have measures the outcome we want. Obtaining data for useful metrics would be difficult, and it would also lay bare some uncomfortable truths about the priorities of healthcare systems that our current metrics hide.

For example, % left without being seen (LWBS). Super easy to measure. Look at everyone that registers in a given time period (usually 12a-12a or 7a-7a), that's your denominator. Look at everyone that registered during that period that doesn't have a note from a provider (or easier but less precise have an unskippable flag that requires whoever's removing the patient from the tracking board to put in the disposition as LWBS), boom numerator. Divide and multiply by 100 and you've got a number that causes contracts, directors, and management to soar or smash upon the rocks.

But what is the actual goal of reducing LWBS? That's where the unifying clarity of a made up, easy to calculate number starts to fragment.

As a doc, did anyone leave from the waiting room that was sick and will suffer negative consequences from their delay in care? That's stupidly difficult to measure. It's unlikely they'll return to the same hospital system and because they were never seen in the first place, it's hard to say how sick they were when they left.

If you're the hospital, what you'd care about is the percentage of patients that leave who would have paid their bill if they stayed and the percentage of patients who will file formal complaints with an outside regulatory agent or seek legal action because of their wait prior to leaving. Again that's a number that's difficult to obtain (especially with a reasonable lag time given complaints/legal action often shows up weeks to months after event) and it's a little too on the nose for anyone that's not in the C-suite.

Useful data is really hard to get, and usually hard to interpret. For all our claims as a knowledge based and enlightened field, the statistical literacy of the people in charge is appalling. So any vaguely complicated statistical work gets offloaded, usually onto a 3rd part who has a vested interest in creating chronic dissatisfaction with their particular metric. Press-Ganey is at the vanguard of this phenomenon.

Any company could have hired a statistician to create a survey of patient satisfaction and then deliver that survey to consumers of healthcare. A big company could have aggregated results from many different hospitals and published that data broken down by hospital size/type so you could compare your hospital score to similar hospitals and set goals of getting x% improvement on your raw score next quarter. It takes a super wrinkly brain to instead report out and standardize PERCENTILE RANKING as the measure of success at patient satisfaction. It's just genius because what should have been a reasonable goal (all hospitals want to hit a score of 80+) instead becomes something that's mathematically impossible (all hospitals want to have better patients sats than 80% of the other hospitals). And as the industry as a whole focuses on patient sat, the floor keeps getting raised so the vast majority of hospitals are compressed within a handful of points on their raw score. This leads to super fun swings were a randomly bad survey or 2 can plummet your percentage 10-20 points. On the individual provider level, the whipsaw effects of this system make it almost uninterpretable and as a director it becomes difficult to use it in a meaningful way since the biggest predictor of doc score is the total ER score.

 

[RustedFox]

Yeah, but we don't pick metrics based on how useful they are. We pick measurements based on how easy they are to obtain. Then we pretend like metric we have measures the outcome we want. Obtaining data for useful metrics would be difficult, and it would also lay bare some uncomfortable truths about the priorities of healthcare systems that our current metrics hide.

For example, % left without being seen (LWBS). Super easy to measure. Look at everyone that registers in a given time period (usually 12a-12a or 7a-7a), that's your denominator. Look at everyone that registered during that period that doesn't have a note from a provider (or easier but less precise have an unskippable flag that requires whoever's removing the patient from the tracking board to put in the disposition as LWBS), boom numerator. Divide and multiply by 100 and you've got a number that causes contracts, directors, and management to soar or smash upon the rocks.

But what is the actual goal of reducing LWBS? That's where the unifying clarity of a made up, easy to calculate number starts to fragment.

As a doc, did anyone leave from the waiting room that was sick and will suffer negative consequences from their delay in care? That's stupidly difficult to measure. It's unlikely they'll return to the same hospital system and because they were never seen in the first place, it's hard to say how sick they were when they left.

If you're the hospital, what you'd care about is the percentage of patients that leave who would have paid their bill if they stayed and the percentage of patients who will file formal complaints with an outside regulatory agent or seek legal action because of their wait prior to leaving. Again that's a number that's difficult to obtain (especially with a reasonable lag time given complaints/legal action often shows up weeks to months after event) and it's a little too on the nose for anyone that's not in the C-suite.

Useful data is really hard to get, and usually hard to interpret. For all our claims as a knowledge based and enlightened field, the statistical literacy of the people in charge is appalling. So any vaguely complicated statistical work gets offloaded, usually onto a 3rd part who has a vested interest in creating chronic dissatisfaction with their particular metric. Press-Ganey is at the vanguard of this phenomenon.

Any company could have hired a statistician to create a survey of patient satisfaction and then deliver that survey to consumers of healthcare. A big company could have aggregated results from many different hospitals and published that data broken down by hospital size/type so you could compare your hospital score to similar hospitals and set goals of getting x% improvement on your raw score next quarter. It takes a super wrinkly brain to instead report out and standardize PERCENTILE RANKING as the measure of success at patient satisfaction. It's just genius because what should have been a reasonable goal (all hospitals want to hit a score of 80+) instead becomes something that's mathematically impossible (all hospitals want to have better patients sats than 80% of the other hospitals). And as the industry as a whole focuses on patient sat, the floor keeps getting raised so the vast majority of hospitals are compressed within a handful of points on their raw score. This leads to super fun swings were a randomly bad survey or 2 can plummet your percentage 10-20 points. On the individual provider level, the whipsaw effects of this system make it almost uninterpretable and as a director it becomes difficult to use it in a meaningful way since the biggest predictor of doc score is the total ER score.

Right.

So, get rid of it. Altogether.
Saves money.
Do the right thing each time.

Problem solved.

 

[GeneralVeers]

Right.

So, get rid of it. Altogether.
Saves money.
Do the right thing each time.

Problem solved.

But you are forgetting the true purpose of metrics......it's non-payment. They like to move the bar on us. I remember in med school when charting was: "Chest pain, admit". They moved it to this silly system of having to document a ridiculous HPI, 8 PE points reviews, and nonsense, time-wasting ROS in an effort catch us. When we got good at automating/scribing our way out of that, they introduced metrics. With metrics they can easily move the bar to whatever they want in order to reject a certain amount of reimbursement.

 

[EctopicFetus]

But you are forgetting the true purpose of metrics......it's non-payment. They like to move the bar on us. I remember in med school when charting was: "Chest pain, admit". They moved it to this silly system of having to document a ridiculous HPI, 8 PE points reviews, and nonsense, time-wasting ROS in an effort catch us. When we got good at automating/scribing our way out of that, they introduced metrics. With metrics they can easily move the bar to whatever they want in order to reject a certain amount of reimbursement.

Also control over docs. You have a gang of idiots telling you what you are supposed to do. Imo it’s them asserting dominance over you. Just like pg scores.

 

[GeneralVeers]

Also control over docs. You have a gang of idiots telling you what you are supposed to do. Imo it’s them asserting dominance over you. Just like pg scores.

Nurses do have an inferiority complex, and love to boss doctors around. Like when they tell me I can't have a drink at my workstation.

 

[Birdstrike]

The bad new is, what @Arcan57 is saying above, is stone cold correct. The hospital businessmen and government regulators have successfully won the messaging game of convincing everyone with the ability to affect policy, that these metrics equal 'quality' care and 'performance.'

They've won, and kicked the crap out of us so bad in this realm, we never saw it coming before it was too late.

They've dovetailed the metrics = quality win into the (unproven) conclusion that improving the metrics improves patient outcomes. Furthermore, if you buy into that, the logical conclusion from payers (the biggest of which are governments, Care/Caid) is that they should pay for this improved 'performance' and punish (not pay for) lack of performance.

This successfully gets you from metrics = quality = pay. Bad metrics = lack of quality = no pay.

And there's no getting out of it, folks. They've got us up against the wall, ropes and in full check-mate. Stick a fork in us. We lost this one.

I've tried to make the points that overreliance on metrics is unethical and abusive, and its won points with docs, but fell on deaf ears everywhere else. Like @Arcan57 says, action will not be taken against these metrics until and unless we can overwhelmingly persuade that majority that they harm people, not just those working in EDs, but mainly the patients. Otherwise, they'll never care. And it's probably too late. It's entrenched de facto as law.

Unless, docs get so fed up the abandon their posts, like has happened in the tort reform realm. With tort reform, it's easier to persuade that defensive medicine harms patients. But still drastic measures had to be taken before real change happened in that realm, like entire specialties leaving entire cities and states, that acted as judicial hellholes.

 

[Birdstrike]

Here's something else that I think is getting missed in this whole "CMGs are bad" "ACEP should ban CMG members" stuff, which I understand. Because I do not think they care about the average pit doc. Both entities have huge flaws.

If you take down CMGs, a whole lot of EM docs are out of jobs. And if you ban CMG docs from ACEP, you've a whole lot of EM docs that go from poorly represented to totally unrepresented. Because that's >70% of EM docs: Non-owners. Dedicated employees, of someone else.

We got to this point because EM docs either didn't want to be practice owners or failed to have the business killer instinct to keep that space from CMGs. CMGs may be an inferior solution to EM physician employment, because they may be the only remaining solution to EM employment.

Shorter version:

"Fight the power" is great. But you've got to have an actionable plan to take power, a plan to enact once you've got it, and the skills plus desire to keep it.

 

[Arcan57]

Right.

So, get rid of it. Altogether.
Saves money.
Do the right thing each time.

Problem solved.

The powers that be tried that. We used to be able to largely charge what we wanted for whatever care we deemed appropriate. As a profession (EM as a specialty didn’t really figure in to the landscape at this time), we used that opportunity to maximize income without sufficient consideration for patient outcome. The idea that more care is always better became entrenched during this time, especially when that care came in the form of lucratively reimbursed procedures. With the rise of nationwide data sets that physicians didn’t control, it became obvious that a lot of care being provided wasn’t worth the cost. We had a moment at that time when we could have taken a hard look at physician practice and self-regulated by losing some income to preserve future autonomy for our specialty. If you’re familiar with people, you have probably guessed this isn’t the option we chose.

 

[Rekt]

Here's something else that I think is getting missed in this whole "CMGs are bad" "ACEP should ban CMG members" stuff, which I understand. Because I do not think they care about the average pit doc. Both entities have huge flaws.

If you take down CMGs, a whole lot of EM docs are out of jobs. And if you ban CMG docs from ACEP, you've a whole lot of EM docs that go from poorly represented to totally unrepresented. Because that's >70% of EM docs: Non-owners. Dedicated employees, of someone else.

We got to this point because EM docs either didn't want to be practice owners or failed to have the business killer instinct to keep that space from CMGs. CMGs may be an inferior solution to EM physician employment, because they may be the only remaining solution to EM employment.

Shorter version:

"Fight the power" is great. But you've got to have an actionable plan to take power, a plan to enact once you've got it, and the skills plus desire to keep it.

This doesn't make sense. Usually when CMGs lose contracts from hospitals, the hospital will typically offer jobs to whoever is working there. It's not like the hospital will be magically staffed after. In fact, most places increase staffing once they dump a CMG contract (poor satisfaction, poor throughput, etc, which is fixed by increased staffing). If CMGs ended tomorrow, there would be many places hiring.

 

[Arcan57]

This doesn't make sense. Usually when CMGs lose contracts from hospitals, the hospital will typically offer jobs to whoever is working there. It's not like the hospital will be magically staffed after. In fact, most places increase staffing once they dump a CMG contract (poor satisfaction, poor throughput, etc, which is fixed by increased staffing). If CMGs ended tomorrow, there would be many places hiring.

Typically when a CMG loses a contract, they lose it to another CMG. There are exceptions (Memorial Hermann kicking out Team in Houston for example), but those aren't the rule. I'd really need to see some data that supports increased staffing after dumping a CMG. In fact, inability to recruit new docs is a one of the major reasons non-academically affiliated hospital systems tend to partner with CMGs rather than have EPs as employees. Even if they wanted to significantly increase staffing post split, most wouldn't be able to do so. The reason things tend to be the same to slightly better compensation-wise immediately post split is that even a couple of docs turning down the hospital's offer can cripple the department.

 

[RustedFox]

Typically when a CMG loses a contract, they lose it to another CMG. There are exceptions (Memorial Hermann kicking out Team in Houston for example), but those aren't the rule. I'd really need to see some data that supports increased staffing after dumping a CMG. In fact, inability to recruit new docs is a one of the major reasons non-academically affiliated hospital systems tend to partner with CMGs rather than have EPs as employees. Even if they wanted to significantly increase staffing post split, most wouldn't be able to do so. The reason things tend to be the same to slightly better compensation-wise immediately post split is that even a couple of docs turning down the hospital's offer can cripple the department.

Sounds like the hospital needs to make the right play, and be sure the offer is palatable for the docs so they don't leave.

The money is there. They might have to (gasp!) have an administrator forego a bonus.

 

[Birdstrike]

This doesn't make sense. Usually when CMGs lose contracts from hospitals, the hospital will typically offer jobs to whoever is working there. It's not like the hospital will be magically staffed after. In fact, most places increase staffing once they dump a CMG contract (poor satisfaction, poor throughput, etc, which is fixed by increased staffing). If CMGs ended tomorrow, there would be many places hiring.

It does make sense. Because for the CMG to lose a contract and be replaced by some entity where you’re not an employee being ordered around, you’ve got to run the group.

Yes, you, not some other boss you like, but literally you need to run the group.

If you’re not the boss, you’re going to feel bossed around. Because all bosses are the same. Every single one, does stuff different than you would. Every one.

 

[oldtown]

Typically when a CMG loses a contract, they lose it to another CMG. There are exceptions (Memorial Hermann kicking out Team in Houston for example), but those aren't the rule. I'd really need to see some data that supports increased staffing after dumping a CMG. In fact, inability to recruit new docs is a one of the major reasons non-academically affiliated hospital systems tend to partner with CMGs rather than have EPs as employees. Even if they wanted to significantly increase staffing post split, most wouldn't be able to do so. The reason things tend to be the same to slightly better compensation-wise immediately post split is that even a couple of docs turning down the hospital's offer can cripple the department.

This brings up an interesting question- with the current slow motion train wreck the job market is, will we start seeing hospitals taking contracts back from CMG’s and employing their own docs, since recruitment will be so easy, even a hospital can do it? I would not be surprised.

 

[Birdstrike]

This brings up an interesting question- with the current slow motion train wreck the job market is, will we start seeing hospitals taking contracts back from CMG’s and employing their own docs, since recruitment will be so easy, even a hospital can do it? I would not be surprised.

Good question. Historically hospitals have tried to avoid this, since recruiting is a big expense and inefficient time suck. It used to be outlawed actually, in many locations, as an 'unethical conflict of interests.' But some have started doing this anyways. So we'll see.

If they can make money doing it, they do it. If they lose money on it, they'll continue to farm it out.

 

[Arcan57]

Good question. Historically hospitals have tried to avoid this, since recruiting is a big expense and inefficient time suck. It used to be outlawed actually, in many locations, as an 'unethical conflict of interests.' But some have started doing this anyways. So we'll see.

If they can make money doing it, they do it. If they lose money on it, they'll continue to farm it out.

It's getting expensive for hospitals to have docs that aren't under their control, so I'd expect as recruiting becomes easier that you'll see more employed physicians. I'm not sure if hospitals themselves will be the ones doing the recruiting, as you mentioned it's expensive and resource intensive. I can imagine a world where the job market is tight enough that independent recruiters start routinely getting good candidates to shop around. Although as the market gluts, things like signing bonuses (which is how recruiters make their $$$) are going to go away which will remove some of the incentive for recruiters. I think we will see some sort of (floppy?, anemic?) national effort by ACEP in the name of getting docs jobs, hopefully with some transparency involved.. Will that mean ads will specifically state that they're recruiting because their last two docs were killed by cannibal hill folk? Only time will tell.

 

[Old_Mil]

I would like to see a consensus statement from ACEP recommending more robust program accreditation requirements to ACGME.

My ideas:
100 intubations
(75 was found to be the number needed to reach 90% success rate by avg EM resident, so at 100, almost all should be competent How many intubations does it take to become competent?)

200 Adult Medical Resuscitations

50 Adult Trauma resuscitations

50 Pediatric medical/trauma resuscitations

50 CVCs

Volume must be 10,000 pts/yr/resident, of patients seen in the resident areas. For example a hospital with a 60,000 per year volume but only sees 40,000 in the resident area (not fast track or triage/dc) can have 4 residents.

Trauma must be completed at a level 1 or 2 trauma center.

And most importantly, simulated procedures for airways, resus, chest tubes, and deliveries don’t count.

If you cant figure it out, your program loses accreditation or elects to close down. And if HCA/CMGs insists on using residents as cheap labor and destroying the market, let’s at least make them train the new docs adequately.

All great ideas. But 50 PEDS resuscitations in 3-4 years seems like a nearly impossible target. I bet there are PEM attendings that work for 20 years without running into that many. I had very good pediatric EM and PICU training and between med school and residency saw two.

 

[The Knife & Gun Club]

All great ideas. But 50 PEDS resuscitations in 3-4 years seems like a nearly impossible target. I bet there are PEM attendings that work for 20 years without running into that many. I had very good pediatric EM and PICU training and between med school and residency saw two.

Guess it defines how you’re defining resuscitations. I tend to use “unstable vitals requiring rapid interventions and frequent reassessment + substantial risk of rapid deterioration.”

So things like bad asthma exacerbations or status epileptics or pedi transplants with weird infections would qualify.

But that may be too broad a definition by some opinions for sure.

 

[Sushirolls]

Here's something else that I think is getting missed in this whole "CMGs are bad" "ACEP should ban CMG members" stuff, which I understand. Because I do not think they care about the average pit doc. Both entities have huge flaws.

If you take down CMGs, a whole lot of EM docs are out of jobs. And if you ban CMG docs from ACEP, you've a whole lot of EM docs that go from poorly represented to totally unrepresented. Because that's >70% of EM docs: Non-owners. Dedicated employees, of someone else.

We got to this point because EM docs either didn't want to be practice owners or failed to have the business killer instinct to keep that space from CMGs. CMGs may be an inferior solution to EM physician employment, because they may be the only remaining solution to EM employment.

Shorter version:

"Fight the power" is great. But you've got to have an actionable plan to take power, a plan to enact once you've got it, and the skills plus desire to keep it.

Here's a possible break on the runaway train for all y'all EM docs:

1) Strive to get board certification and ACEP membership tied only to employment with physician owned groups, and have a definition of what constitutes physician own. Immediately, many docs will no longer be employable with the CMGs because they lose board certification which impacts ability to have hospital privilege's at some places and to be paneled with insurance companies.
2) Have pre-made templates of SDG contracts already in PDF ready (prepped by ACEP) to be used by these docs to hastily form their own. I.e. provide the tools they will need to be their own groups, their own leaders. Force the pit doc into the position of ownership and control over their practice.
3) Make this change on like January 5th, with enforcement on January 1st the following year. This gives time for the pit docs to uniformily pull this trigger on their terms on Freedom Day X.

*Even if CMGs or other random entities challenge this, I doubt they will get a stay in court, but will have to fight it out in court. By the time they get a summary, even if unfavorable, the mass transition will have already been completed. The social uproar in EM of why and the what will have already created a complete culture paradigm change. Basically use bureaucracy to fight bureaucracy.

 

[GatorCHOMPions]

Supposedly there was a big virtual summit today with all the big players at the table (leaders of ACEP, SAEM, AAEM, ABEM, etc.) to discuss the job market at present and future. It's anyone's guess what will come of it, if anything.

 

[EctopicFetus]

Supposedly there was a big virtual summit today with all the big players at the table (leaders of ACEP, SAEM, AAEM, ABEM, etc.) to discuss the job market at present and future. It's anyone's guess what will come of it, if anything.

reportedly 7600 too maniocs by 2030. a 20% surplus.

 

[EctopicFetus]

A lot of people are frustrated with ACEP and feel there's more they could do to make the average pit doc's life and career, better. The temptation is to assume they have lots of power you and I don't. Are there concrete actions they could take or are they stuck beholden to administrators, CMGs and government mandates, just like the rest of us?

What are some concrete actions ACEP would take to make things better for EM doctors, if you were President of ACEP?

ACEP should cut ties with anything CMG related. no speakers, no money, no ads, put the red letter C on the CMG people. make it uncomfortable to work for them.

 

[Arcan57]

ACEP should cut ties with anything CMG related. no speakers, no money, no ads, put the red letter C on the CMG people. make it uncomfortable to work for them.

But if you don't know what a CMG is, how can you defend against them? /s

 

[RustedFox]

Supposedly there was a big virtual summit today with all the big players at the table (leaders of ACEP, SAEM, AAEM, ABEM, etc.) to discuss the job market at present and future. It's anyone's guess what will come of it, if anything.

Any word on the outcome?

 

[Rekt]

reportedly 7600 too maniocs by 2030. a 20% surplus.

Guessing this meant 7600 too many docs, oversupply. This should be it's own thread. That's insane and you can bet acep is trying to make the numbers look good as possible even reporting that. Yikes.

 

[southerndoc]

Any word on the outcome?

The sky isn't falling, continue onward. Need more docs. I'm sure that's what came of it.

 

[RustedFox]

Guessing this meant 7600 too many docs, oversupply. This should be it's own thread. That's insane and you can bet acep is trying to make the numbers look good as possible even reporting that. Yikes.

I read it as "7600 maniacs".

 

[GeneralVeers]

I read it as "7600 maniacs".

We just need 2400 more and we will be perfect!

 

[EctopicFetus]

Guessing this meant 7600 too many docs, oversupply. This should be it's own thread. That's insane and you can bet acep is trying to make the numbers look good as possible even reporting that. Yikes.

Yes. I apparently was distracted

 

[GatorCHOMPions]

Any word on the outcome?

Still waiting to hear officially. The initial impressions are, “this needs to be addressed ASAP, but we think we’ll be all right in the long term”.

I’m getting a little more info on the residency creation issue. It seems to boil down to antitrust law, specifically restraint of trade, with ACGME. Anyone know how the successful specialties in this regard are able to limit supply despite this supposed barrier?

 

[Sushirolls]

Fight bureaucracy with bureaucracy. Add an additional metric that needs to be requirement for EM residency that has a high percentage target towards the ones y'all don't like. Granted there may be some collateral damage of others, but look for that key metric.

Get it enacted, and boom, a bunch close.

 

[GatorCHOMPions]

COVID-19 Latest Updates

COVID-19 Daily Updates

www.acep.org

There is a free public webinar tomorrow on the future EM workforce, hosted by ACEP.

 

[RustedFox]

Pfft.
Can't WAIT to hear the next oblivious statement from ACEP.

EDIT: it's going to be "telehealth". I'm crossing the threads; I don't care what Egon says.