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Viewpoint: The Rise and Fall of Emergency Medicine : Emergency Medicine News


EM history, ED management, EM jobs

Doctors had few useful treatments centuries ago. They could do a few things, but most importantly they understood the path of illness, predicted the outcome of a problem, and summoned friendly spirits, such as leeches, and sometimes a herbal remedy to help those in pain. A doctor couldn’t do much, but sometimes he could accurately say, “Get your affairs in order.” You won’t see next spring.

Science began to replace faith in healing. Leeches were cheap, local herbs were available, and healing hands had time to apply their touch and comfort. Science was a bit more expensive.

Medicines, x-ray machines and hospitals cost money. Fees have gone from one chicken to several dollars. Drug producers have gone from a covered wagon selling cures to huge commercial enterprises with the most powerful political lobby in the world. Teams began to form as a new system appeared. Doctors and their nurses (first subordinates, then a separate but equal team) formed a team, and in the beginning this team, with its training and knowledge of medicine, its duty and commitment to the patient first and the promise to adhere to superior ethics, was in charge.

It took a lot of time, commitment and intense study to learn (pre-medical sciences, four years of medical school) and to apply (three to eight years of internship and residency) the knowledge of medicine. That didn’t leave much time to get things under control. The criteria for measuring medical qualifications were clear and often used.

Now that a lot of money was at stake, some businessmen started to “help”. Physician-run hospitals were financially disadvantaged because administration and finance also have a skill set. Doctors and nurses outnumbered administrators during this time and were considered valuable. It was clear that physicians had to be shielded from the financial machine. Physicians should be free to put their patients ahead of financial motivations. Obviously doctors should not be employed, and good laws have been passed to prevent doctors from being employed by and therefore subject to the demands of financially motivated administrators.

However, each administrator needed a few secretaries, and new departments had to be created. New administrators were needed to manage these new departments. Soon, administrators and other managerial staff outnumbered doctors and nurses (and other medically trained caregivers). The criteria for measuring administrative skills were vague and little used. A former hospital CEO I worked with, for example, had no administrative background and no college degree.

Suddenly the doctors were a nuisance. They remembered the days when they were considered important and treated with respect, and they acted a bit grumpy. Administrators complained that doctors were their problem and said they could better control doctors if they were employees. The employment model has been debated and tested. Indeed, physicians were more receptive to requests from an administrator if they could be terminated simply by not renewing an annual contract.

Some doctors objected to being told what surgeries they could perform, how many patients they had to see each hour to meet their quota, and what drugs they could (the expensive ones) and could not (cheaper, but often most proven) prescribe, but some just liked punching the clock and getting a paycheck without all that billing and paperwork hassle. Initially the job was unusual, but it became increasingly common until 2019, when more doctors were employed by hospitals than self-employed for the first time in history.

No more doctors’ lounges. Administrators asked, “Why do doctors need to relax anyway? In fact, it was where physicians talked, collaborated, and coordinated their patients’ care while building relationships with each other, which led to better patient care.

No more parking spaces reserved for doctors. Administrators asked, “Why do doctors have to park nearby anyway?” In fact, going in again and again at night (instead of 9-5) makes it essential to have a nearby spot to avoid walking through a long, icy parking lot in the dark.

Gone is the time needed to perform a thorough history and physical examination. Administrators said, “I like doctors who just order a CT scan ($2,000) instead of wasting time on a physical exam ($69).” Maybe the administrators don’t know that CT delivers the radiation of 500 X-rays, or maybe they just don’t know that X-rays are proven to cause cancer.

Ultimately, the quality of medical care suffers as the big-dollar business model grows and continues to feed on itself. Will patients notice? No. Will new doctors notice? May be. These days, most doctors clock in and out without ever seeing a medical salon.

Then one administrator had an enlightening thought, “Why bother hiring a doctor when I can get a physician assistant or nurse practitioner for half the price? It doesn’t matter to an administrator that doctors have 10 times more education and training; what matters is the price! With the right incentives, a non-physician provider can see as many patients per hour.

Another bright idea! “Why don’t we make our own doctors?” It will help solve this doctor shortage, and we business people know the law of supply and demand, don’t we?

What does the future hold? We have lost control of our destiny, and our patients will continue to pay an ever-increasing price if we don’t take them back. Employees unionize. A union can negotiate better working conditions. When I was in residence, such a thought was beneath my dignity. Now this may be necessary. Can we enact laws preventing the employment of doctors? Should we wait for the government to act? Do you remember what I said about the most powerful political lobby in the world? No significant action will come from this sector.

The only reason I can write this is that I am no longer employed by a high load group of administrators and have 25 years of practice under my stethoscope. Most of our young colleagues do not dare to speak. The old guard will have to take the lead in the actions that must follow.

Or we can just retire and be nursed for our acute IM by a shiny new NPP who lives far left on the Dunning-Kruger curve (the omniscient bliss of almost complete ignorance) while the EP and the cardiologist cover several hospitals from home.

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Dr. Bordenis an emergency physician in Washington State and author of the book Medical wisdom.