I think this really is the future of EM.
Increasing unfunded government mandates leads to an increase in hospital bureaucracy to deal with the government mandates. Bureaucracy deals best with bureaucracy. Independent groups of ER docs are too powerful and unwilling to bow to stupidity. The modern group of graduating residents are not willing to risk financial ruin in putting up their (nonexistent) capital to form staffing corporations. I personally know of 5 different contracts that have gone from independent physician groups to giant megacorporations, with a subsequent mass exodus of well-respected, seasoned ER physicians. Why? The hospital wouldn't cave to their demands as an ER group.
One of the major principles of the Studor philosophy which has cancerously infiltrated every part of medicine is that you need to cut dead meat. My old boss told our group that we were going to get Press-Gainey scores up at all costs, even if it meant 99% turn-over in nurses and physicians. I sat in the rah-rah "inspirational" type meeting where he learned this concept and decided to implement it. Since I left my old ER, the nurses got a new nurse manager who was basically just a little mini-me of administration and started inacting all kinds of weird policies and @#!*% the nurses off. The most seasoned, compassionate ER nurse there took exception and started inciting rebellion. Their response was to kick her out of the ER and put her in charge of education. Imagine! A rural hospital who has a huge chronic problem with staffing their ER with quality experienced ER nurses takes their best nurse out of the ER.
In summary, get used to big brother/ big sister looking over your shoulder and telling you it is their way or the high-way.
Anybody else see a trend toward huge ER staffing corporations obtaining more contracts? Or is my experience unique?
Expect the Unrealistic
Is your experience unique. No. The problem is physician thinking. Yes physician thinking.
We need to change our attitudes and start standing up for ourselves, especially EM physicians.
If such hospitals as you described, literally, couldn't staff their ER, at all because ER physicians and nurses flat out refused to subject themselves to it anymore, things would change.
1)
ER Physicians should flat-out refuse to take jobs as hospital employees and mega-staffing-corporations and insist upon working for independent physician groups (in my opinion).
If ER physicians refused to work for contract groups because such groups turn around and take other ER doctors jobs at lower cost, applying downward pressure on ER physician salary and essentially cutting your pay, then such groups would go bankrupt. But what happens, you guys keep taking jobs with them. Why? Either, they haven't done your homework, they're not aware that such groups cannibalize their own and work against them (not directed at you Jarabacoa, because you seem to get it) or, they just don't care because in the short term it works for them. Or they haven't prepared financially with 6 months cash savings in their bank account so that they can financially survive losing their contract without being forced to be re-hired at a pay cut by the contract group that threw their group out.
Factory workers mobilized in unions and amassed so much power and were so successful accumulating so many benefits they actually crushed GM, the largest corporation in the world at one time. What do docs do? We whine moan and complain and get pushed around and deal with it because we are afraid to be called "rich greedy doctor". (You're also essentially banned from unionizing by the Federal government, see below).
Is the crush of government, contract-group, hospital administration unique to EM? No but it's much, much, much greater. Why? Because (some) patients in the ED or so sick, so injured, so desperate, so in need that for you to do anything but selflessly take care of them without any concern for your own job satisfaction, well being, family life, career or shift-work sleep disorder is considered selfish or cruel. The altruistic nature of (most) physicians, especially EM physician is taken advantage of by the government and hospital administration.
So, what's the point of all this ranting? It is time to focus the negativity towards positive solutions.
Since, EM physicians are de facto government (EMTALA) and/or hospital employees (either outright or treated as such through hospital admin)
without any of the benefits it's time to start having some unrealistic expectations...
ON UNFUNDED GOVERNMENT MANDATES:
2)
No care of EMTALA patients without payment at FAIR MARKET RATES. Yes, FAIR MARKET RATES. Not Medicaid rates, or 2 cents on the dollar. FAIR MARKET VALUE. No excuses, no explanations, no exceptions. Find the money. If you require us by law to treat them, their should be a law requiring you to pay us, and our malpractice. Period. No exceptions . Find the money somewhere or change the law. It's against the law for you, specifically only you as an Emergency Physician, to pick and choose what insurance you accept. The law essentially states you can be paid $100, $1, 1 cent or nothing for a life saved. It's not up to you. It's decided for you. Fortunately, and thank God for it, other physician specialties can choose whether or not to participate in any given insurance plan, Medicaid, Medicare or private. Thank God. If the government takes that away from all physicians. Game over. The profession is dead. Let me be clear, I am NOT suggesting anyone violate EMTALA or any other law. I am suggesting the law be changed to require that ER physicians and hospitals receive payment for such government required care. Whether ObamaCare will result in 1) all patients being insured and, 2) ER physicians getting fair market payments for this care is, to say the least, greatly in doubt, in my opinion.
3). NO,
absolutely no, "medical screening exams" where the physician is expected to "screen" the patient, deem the patient a "non-emergency", turn them away without getting paid (to save the hospital money). At first it seems logical to defer non-emergencies to their PCP. However, there is a critical shortage of PCP, and largely this will never happen. The patients either, won't get care, or they'll just go to a hospital ED without such a policy. What you're doing, for one, is totally angering the patient, and then accepting all of the liability if something goes wrong,
without fair market payment or malpractice converage, for no other purpose than to save the hospital money, not help patient. If your hospital or group tells you they do pay you for these patients, ask them where the money comes from. It should NOT be taken out of funds previously allocated to physician payment (taken out of your right pocket to pay you in your left pocket) but new funds, taken from somewhere else, the CEOs bonus, whatever. No more, no exceptions, no excuses. There's no way, NO WAY, you should be able to be sued for 1 dollar let alone $20,000 or $200,000 or more, for a patient you're required by law to evaluate and prevented by policy or law, to bill. It's coercion by force! It's equivalent to sticking a gun to your head. If you don't think so, what do you think would happen if you refused to do such exams under EMTALA, and got a $50,000 EMTALA fine and refused to pay it? You'd be arrested and dragged into some court at some point. And if you refused to go? You're arrested. If you resist arrest....guns are drawn. This is Federal Law and you don't dare violate it, and shouldn't, but you should be compensated and protected for the great, GREAT benefit you provide to society under the most stressful, difficult and short staffed circumstances.
4)
No laws preventing physician collective bargaining. None.
Wipe the books clean. Why do union workers push huge corporations around and doctors do what they're told and say, "Yes, sir, whatever you say. Okay sir, yes sir" and complain, complain, complain until they're blue in the face with nothing ever changing? Because, amongst other reasons, laws prevent you from joining forces and negotiating as a union.
It's against the law for you to do what any other American worker takes for granted as his God given right. Yes, illegal. Why? So they can tell you what to do without you having a choice. Read this below, written by a lawyer, not even a physician:
"
Current antitrust enforcement policy unduly restricts physician collaboration, especially among small physician practices…there is a profound imbalance in the marketplace between the health insurers who collect premiums to pay for medical care and the physicians who provide medical care. Such an imbalance has resulted in an increasingly unfair and inefficient healthcare delivery system" from Physician Collective Bargaining, by Anthony Hunter Schiff, JD, MPH. Clin Orthop Relat Res. 2009 November; 467(11): 3017–3028.
5) And finally, why, why,
why haven't we eliminated or drastically weakened, Certificate of Need Requirements? They've failed MISERABLY in accomplishing what they were intended to accomplish - reduce health care costs. That's laughable. They've done nothing to reduce health care costs. Nothing has reduced health care costs. Why do we still have a policy requiring hospitals to beg and plead and wait years for approval for hospital beds from government officials who know nothing about health care? Many times, once the permission is granted for a hospital to add bed, and the beds are built, so much time has passed, they already need more! THIS IS INSANE. Read this article from LA TIMES where county officials "gave permission" to L.A. County/USC Medical Center to increase their ED beds from 96 to 137 but forced them to REDUCE the number of inpatient beds from 824 to 600. Now they've got head bleeds boarding in the ED for 34 hours, at times. This is not an isolated mishap. This is happening in lots of places. This
is a real crisis, created by the same government officials who claim to protect us and patients. Talk about an EPIC FAIL. Why can't L.A. County/USC Medical Center add more beds right now? Although I have no such inside knowledge of their situation, I guarantee you they'd have to ask for a certificate of need from the same board that denied them the beds in the first place. Why are we so afraid to add TOO MANY hospital beds? Could someone please give me an example of where TOO MANY hospital beds caused any problem, let alone anywhere near the crisis certificate of need policies have created by limiting beds? Please.
Why aren't we questioning this insanity?
6) More
Physicians should run for public office. The reasons are obvious. We only have a handful of physicians in Congress nationally and it's not enough. We're subjected to whatever misguided policies politicians can craft to rule our domain and have virtually no hand in shaping the process. The results have been devastating already.
REGARDING PRESS-GAINEY SCORES:
7)
Mandatory 30 min meal break per 8 hours worked. Once you're done laughing, and get over how unrealistic it sounds, follow my logic. I know what you're thinking, this guy is lazy and probably only saw 8 patients per shift when he was in the ED. Wrong, wrong and wrong. I busted my tail when I was in the ED. And I'm not talking about leaving the bedside of a critical patient and punching out. I'm talking about working in a scheduled, mandatory break at some point during a shift, every shift, except in extreme circumstances. Follow me:
Why a mandatory break? Again, if you are a de facto government/hospital employee, which you are, you should get the benefits. Period. End of discussion.
If you're expected to kill yourself seeing 30, 40 or more patients per 12 hour shift, and
stop to order your patients a meal tray to keep your Press Ganey stellar, you should get a meal too, without being interrupted unless it's an emergency. A real emergency, not a hangnail patient with insurance that's been waiting over the allotted 30 min time goal. It's one thing if
every patient is critical, but when you're expected to kill yourself to "greet or treat" every patient within some ridiculously low and arbitrary time window, when the vast majority are not sick, there should be some time scheduled for a mandatory break. Nurses in the ED do it. All other government and hospital employees do it. The hospital CEO and ED director do it. You'll be able to treat your patients better, and provide "better customer satisfaction"; if you're rested and fed. Again, the point isn't "Are you tough enough?", because everyone knows you are. But your residency and 30 hour shifts without a break are (should be) over, and if you're going to have to be burdened by the requirements and regulations of a de facto government/hospital employee, you should get the benefits. Don't let the hospital or you're group tell you "We're too busy".
Lie #1. It's a complete lie.
They staff the ED precisely the way they want it, based on how much $ they want to allocate to the ED, within a decimal of patients per physician per hour. They have the place exactly the way they want it. Your ED director knows it. There's a reason he's cut back his shifts. It's no accident you're getting killed each shift. It's not to help people and save lives (even though you are, this is essentially irrelevant). These policies are created to ram as many patients through the cash machine to make money for the hospital period. To them, the more overwhelmed you are with insured patients with non-emergencies, the better. Skip lunch, hold your bladder, move the meat. They take advantage of the legendary physician work ethic and perpetuate the myth that if you just work a little harder...
you'll get caught up. Ever been in an ED that's caught up? I bet not. I have. You know the first thing they did? They cut coverage! They could have double the coverage if they want. Increase the amount you pay the docs and nurses to work until they sign up for more shifts. It's very simple.
They'll tell you, "there's an ER physician shortage, that's why we're overwhelmed." Lie #2. There are plenty of ER physicians to take care of the
EMERGENCIES in the United States. However, when you raise the bar to say ALL COMERS, the vast majority of whom do not have life or life threatening "emergencies", no matter how inappropriate, or un-sick, or non-emergent, and say they must be seen within 30 minutes (or some other arbitrary time frame) you just manufactured a false "CRISIS" that can be used to motivate. All of a sudden you're overwhelmed, everyone is waiting too long, you're pushed to work harder, faster at all hours of the night with no excuses to deal with the never ending crush of patients all to be seen within 30 min no matter how many come in. Now you have a "shortage" and you're expected to fix it every shift.
Ask one of your (non-emergency patients) if he gets a mandatory lunch at work. I bet you he does. Ask him if he gets time and a half for overtime, nights, weekends and holidays. Again, the point isn't "am I tough enough to do it?"; It's not about laziness or being a slacker. You're able to crank through 40 patients in a 12 hour shift with a few critical patients and a boat load of non-emergencies without taking a lunch break, or bathroom break. The point is that they've made you a de facto government/hospital employee and burdened you with requirements but have not given you the benefits. And in one of the busiest most stressful specialties in one of the most stressful professions of the planet, you deserve it.
You deserve it. Why is expecting a lunch break such radical thinking?
8)
Mandatory time and a half per any hour worked greater than 8 in a shift, or 40 in a week, for nights and holidays.
Why? Again, all other hospital, government, and corporate employees get it. Why shouldn't you? If you work for a group and you don't think you're a hospital employee, just start changing the rules in your ED, try to fire an incompetent employee, change the on-call policy, the triage policy, the staffing ratios without the hospitals and/or governments permission. You'll find out you're essentially the highest paid hourly worker on the hospital payroll. Nothing more. Until you start demanding it and expecting these things, you're right, it'll never happen.
9)
Workers Compensation for Shift Work Sleep Disorder caused by your job.
If your job causes you to have legitimately have a disease listed in the DSM-IV (Circadian Rhythm Sleep Disorder - Shift Work Type) or any other textbook, you should be compensated for it. Period. Don't suck it up, because you can, or you're tough or superhuman or whatever. No other segment of society would let their job cause them a legitimate disease or disorder and not expect to be compensated for it, or have rules and regulations enacted to protect them.
Radical change requires radical thinking. I don't expect anyone to snap their fingers and these things will become reality tomorrow. But until you think and know you deserve better nothing can change. ER doctors deserve better. Patients deserve better.
Think Big.
Expect the Unrealistic.
