- Email: [email protected]
A national survey of board-certified emergency physicians: Quality of care and practice structure issues
Original Contributions
A National Survey of Board-Certified Emergency Physicians: Quality of Care and Practice Structure Issues SCOTT H. PLANTZ, MD,* LANCE W. KREPLICK, MD,t EDWARD A. PANACEK, MD,::I:TEJAS MEHTA, MPH, MBA,§ JON ADLER, MD,II ROBERT M. McNAMARA, MD¶ The opinions and experiences of board-certified emergency physicians regarding employment structure and finances, professional society policies, and quality of patient care have never been formally studied. A survey questionnaire was sent to a random sample of 1,050 emergency physicians certified by the American Board of Emergency Medicine. The survey contained 29 multiple choice questions. Of the 1,050, 465 (44.3%) of the surveys were returned. Respondents averaged 13.5 years of emergency medicine practice, 83% were members of the American College of Emergency Physicians, and 44% were emergency medicine residency trained. Seventy-five percent felt they had been financially exploited by the emergencydepartment contract holder and 49% considered leavingtheir employer because of unfair business practices. Fifteen percent have been terminated without due process/peer review, and 11% have been forced to leave a position, move, or pay compensation because of noncompete clauses. The majority reported encountering instances of substandard emergency medical care, most commonly in settings with multihospital contract company coverage. The majority also believe their specialty societies should address issues of employment structure and quality of patient care standards. (Am J Emerg Med 1998;16:1-4. Copyright© 1998 by W.B. SaundersCompany) Although controversial for many years,1 emergency medicine practice issues have recently received increased attention. 2-5 These include concerns about financial relationships, employment arrangements, practice environment, and quality of care. Only one study, very limited in scope, 6 regarding the practice environment of emergency physicians has been published in the literature. More commonly, discussions regarding these issues have occurred in editorials and the From the *Department of Emergency Medicine, Chicago Medical School and Mt Sinai Medical Center, Chicago, IL; the tDepartment of Emergency Medicine, University of Illinois and Christ Hospital and Medical Center, Oak Lawn, IL; the :~Department of Emergency Medicine, UC Davis Medical Center, Sacramento, CA; the §University of Illinois College of Business, Chicago, IL; the IIDepartment of Emergency Medicine, Massachusetts General Hospital, Boston, MA; and the ¶Department of Emergency Medicine, Allegheny University of the Health Sciences, Philadelphia, PA. Manuscript received October 4, 1997; accepted November 4, 1997. Address reprint requests to Dr Plantz, Suite 103, 4450 Gulf BIvd, St Pete Beach, FL 33706. Key Words: Emergency physicians, survey, quality of care, group practice, politics. Copyright © 1998 by W.B. Saunders Company 0735-6757/98/1601-0001 $8.00/0
print 24 and television media, generally focusing on anecdotes and suffering from a lack of objective data. Although it is likely that issues of practice structure and politics within the specialty play a role in determining satisfaction with practice, physician well-being, and quality of care, the position of emergency physicians on these issues has not been formally investigated. The purpose of this study was to determine the opinions and quantitate the experiences of board-certified emergency physicians in some of these controversial areas.
MATERIALS AND METHODS A list of 10,500 diplomates of the American Board of Emergency Medicine (ABEM) was obtained from the American Board of Medical Specialties (ABMS) directory of certified emergency physicians. A computer randomization program was used to randomly select 10% (1,050) for the survey. The first mailing was in July, 1995. Second (October, 1995) and third (January, 1996) mailings were sent to nonrespondents. All responses received between July 1, 1995 and June 28, 1996 were included in the study. After receipt, all surveys were handled in an anonymous fashion such that the sender could not be identified. The survey consisted of 29 closed-ended questions. Five related to respondent background information and current employment status. Of the others, 2 questions related primarily to financial issues, 11 to professional society policies, 9 to practice structure and experience, and 2 to quality of care. All questions were multiple-choice with mutually exclusive answer categories. The majority of questions were framed in the form of a question, with three answer options. An example of such a question is the following: "Have you ever been forced to leave a position, move, or pay compensation because of a non-compete clause in your contract?" The potential answers were, "yes," "no," or "no opinion." The questions relating to quality of care had several subsections relating to background of the practitioner involved and the employer or practice setting. Survey responses were collated by question and, where appropriate, by category. This was performed by a nonphysician. Simple descriptive statistics were used to summarize responses. The survey study was deemed exempt from human subjects review as meeting exemption category 2 (45 CFR 46.101B).
RESULTS Four hundred sixty-five of 1,050 (44.3%) emergency physicians responded to the survey. Respondent emergency
2
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 16, Number 1 • January 1998
physicians' demographic information is listed in Table 1. The vast majority were American College of Emergency Physician (ACEP) members, and the most common employment setting was in democratic partnerships. Respondent demographics were similar to data for the entire group in the areas of emergency medicine residency training (44% v 48%, personal communication, ABEM) and ACEP membership (83% v 78%, personal communication, ACEP). The clear majority of respondents (78%) identified a democratic partnership as their preferred practice setting, followed by those preferring hospital employee status (13%). Only 4% preferred working in a sole proprietorship and 5% for a multihospital contract company (MHCC). Table 2 summarizes the responses to many of the questions relating to employment practice and financial issues. Not all respondents answered all questions. The number answering each question is indicated, and percentages in each answer category are taken from that number. A surprisingly large majority (75%) of respondents have felt financially exploited, at some point in their career, by the holder of the emergency department contract. Of these, the most common settings for the perceived exploitation were MHCC (29%), and sole proprietor (28%) employers. Ten percent felt financially exploited as hospital employees and 8% by democratic partnerships. Half the respondents felt exploited in terms of work schedule; again, the most common practice settings for this were sole proprietorships (19%) and MHCCs (17%). A significant number of respondents reported being terminated without "due process" (15%) or being forced to leave a position, move, or pay compensation because of a "non-compete" clause. Unfair business practices were considered so extreme by 49% that they considered leaving the employer. Several questions related to the role and policies of emergency medicine professional societies. Eighty-two percent responded that their society leadership should be elected in a democratic (one-member, one-vote) system. Eighty percent believed that "fellowship" status should not be offered to non-board-certified emergency physicians, and 55% indicated that only board-certified emergency physicians should be allowed full voting status. Sixty-seven percent responded that professional emergency medicine societies should develop standards for certifying emergency departments, and 77% thought societies should establish quality of care guidelines applicable to emergency medicine management organizations. Eighty-nine percent indicated a specialty society should lobby for due process/peer review for emergency physicians, and 63% indicated a specialty TABLE 1. Respondent Demographic Information Years of emergency medicine practice (average) Member of ACEP Member of AAEM Emergency medicine residency trained Current employment setting: Hospital employee Democratic partner group University faculty MHCC Sole proprietor contract Other
13.5 years 83% 29% 44% 18% 38% 7% 18% 10% 9%
TABLE 2. Responses to Employment Practice Questions
N* 1. Terminated without due process? 2. Forced to leave, move, or pay because of "noncompete" clause? 3. Considered leaving emergency medicine because of unfair business practices? 4. Job threatened by voicing "quality of care" concerns? 5. Job threatened by voicing equitable compensation concerns? 6. Felt financially exploited by emergency department contract holder? 7. Felt schedule was exploited by emergency department contract holder?
Yes
No
No Opinion
423 15% 85%
0%
423 11% 88%
1%
432 49% 47%
4%
448 23% 77%
NA
434 27% 73%
NA
465 75% 25%
NA
465 51% 49%
NA
*Number of respondents answering the question.
society should lobby for a cap on management fees. Fifty-eight percent of respondents believed that a specialty society should lobby to prohibit the buying and selling of emergency department contracts. Eighty-three percent of the respondents suggested that a specialty society should risk litigation to establish policy that discourages unfair treatment of emergency physicians. Two survey questions asked if the respondents had encountered substandard emergency care in their practice and, if they had, associated with which types of practitioners and employment structure settings. The responses are summarized in Table 3. Substandard care was most commonly perceived to be provided by physicians without certification TABLE 3. Responses to Quality of Care Questions N Practitioner type associated with perceived substandard care Emergency medicine boarded/eligible Other boarded/eligible Not boarded/eligible Moonlightingemergency medicine resident Moonlighting nonemergency medicine resident Practice settings associated with perceived substandard care Democratic partnership Sole proprietorship Hospital employee MHCC
None Rare* Occasional* Frequently*
416 10% 54%
29%
7%
411
25%
50%
22%
387 4% 10% 335 12% 29%
36% 43%
50% 16%
355
3%
7%
9%
36%
48%
292 21%
54%
19%
6%
295 11% 23% 266 15% 28% 309 6% 12%
42% 41% 32%
24% 16% 50%
*Rare = 1 to 2 times; occasional = 3 to 4 times; frequently = more than 4 times in career.
PLANTZ ET AL • EMERGENCY PHYSICIANS' SURVEY
in any specialty and by moonlighting non-emergency medicine residents, and was least often associated with emergency medicine boarded/eligible physicians. MHCC and sole proprietorship contract settings were reported most frequently as associated with substandard care. Twenty-three percent of respondents reported that they had been threatened or actually lost an employment position after voicing concerns about quality of care issues. Seventyseven percent of respondents favored legislation establishing standards for emergency staffing, such as a minimum of one board-certified emergency physician at all times in all level 1 and 2 trauma centers. Sixty-six percent favored legislation establishing minimum acceptable levels of training prior to working single coverage in any emergency department and 84% wanted emergency medicine professional societies to take the position that emergency medicine is best practiced by emergency medicine-certified physicians.
DISCUSSION Controversy is not new to emergency medicine, but increasingly, practice aspects have received attention. 2-7 No formal study of these issues has previously been published. As a result, much of the debate regarding the potential effects of different emergency physician employment structures, and other controversies, has lacked objective data. This study is the first attempt to quantitate emergency physician opinions and experiences in these areas. Nationally, corporate entities control an increasingly larger share of emergency services, s although our findings suggest emergency physicians have their best experiences in democratic partnerships and 78% would prefer to work in democratic groups. The vast majority (75%) of emergency physicians have at one point in their career felt financially exploited by the owner of the emergency department contract, most commonly those owned by sole proprietors and multihospital contract companies. Considering nearly half of our respondents have considered leaving their employer because of unfair business practices--and multiple reports indicate emergency medicine has a high attrition rate9-11--the impact of this issue on physician satisfaction and well-being warrants further scrutiny. We found that due process/peer review is very important to certified emergency physicians and 89% favored lobbying by specialty societies for due process/peer review for emergency physicians. However, it is unclear which entity (eg, hospital or group) would be expected to grant the due process. This survey did not examine the issue in detail. There does not appear to be a clear consensus by emergency medicine societies on this issue. 5,12Part of the reluctance by professional societies involves a concern that litigation might result from taking positions on these issues. Although 83% of the study respondents felt their specialty societies should risk litigation to address this issue, it is unclear if they are willing to pay for the potential costs, ie, with higher dues payments, etc. Given that both the American Medical Association (AMA) 13 and the JCAHO 14 strongly advocate due process/ peer review prior to physician termination, it is alarming that our study found that 15% of emergency physicians have
3
been terminated without appropriate due process/peer review. The AMA, 15 the American Academy of Emergency Medicine (AAEM), 12 and ACEP 16 all oppose the use of noncompete clauses in physician contracts, yet 11% of our respondents have had to leave a position, move, or pay compensation because of such a clause. Our results also suggest that many emergency physicians are not allowed to speak openly about perceived inequalities within their practice. About 25% of responding emergency physicians have experienced threats of termination after voicing complaints regarding issues of equitable compensation or scheduling. Perceptions of uneven quality of clinical care in emergency departments have received attention in the lay media and elsewhere. The experiences reported by the emergency physicians in our study seem to substantiate these concerns. Our respondents reported being aware of numerous instances of substandard emergency care, most commonly associated with physicians not boarded in any specialty or moonlighting (non-emergency medicine) residents. This view is supported by a limited body of literature that demonstrates board-certified emergency physicians provide better quality and more efficient care lv,~s and are preferred by emergency department nurses. 19 Contract companies, nonetheless, may have a financial incentive to hire non-boardcertified emergency physicians, including ones working in the field part-time, and continued expansion of these groups could detract from the quality of care provided. This observation was further supported by the survey finding that substandard care was most frequently reported when the contract was held by MHCCs. Compounding this issue was the fact that MHCCs were reported as the most likely employers to threaten or terminate a physician for voicing concerns on quality of care issues. Perhaps for this reason, the vast majority of respondents believed minimum standards should be established for single coverage emergency department staffing in general, and particularly stringent requirements for emergency department staffing at level I and II trauma centers. This study has limitations that may affect interpretation of the results. The overall response rate is lower than the goal generally desired for such surveys. However, it is similar to the response rates often obtained in survey studies involving large numbers of emergency physicians. 6,11Additionally, the respondents appear to be generally representative of the overall group in the baseline demographic areas compared. Second, this survey only involved board-certified emergency physicians and the results should not necessarily be extrapolated to all physicians practicing in the emergency department. However, a prior, smaller survey was done using a random sample of the AMA/PDR list of physicians primarily practicing emergency medicine. 16 That list included a large number of non-board-certified emergency physicians. Some of the questions covered the same emergency medicine practice issues and the results were quite similar. Finally, these survey results represent physician self-reporting and opinion. There was no independent or objective confirmation of actual exploitative practices, termination, lack of due process, or substandard care.
4
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 16, Number 1 • January 1998
C0NCLUSl0NS As the first large survey to address many controversial practice issues in emergency medicine, this study found physician exploitation is perceived to be very high and terminations without due process and conflicts over "noncompete" clauses are common. A democratic partnership is the employment structure clearly preferred by a large majority of the responding board-certified emergency physicians. The majority want their professional specialty societies to address issues of employment arrangements and patient care standards. Concerns about an association between substandard clinical care and certain categories of practitioners, or employment structures, warrant further investigation.
REFERENCES 1. Hellstern RA: National contract groups. J Am Coil Emerg Phys 1979;8:493-495 2. Danzl DF: Restrictive covenants: What would they have us teach? Academic News and Views (ACEP Publications). 1994:4-5 3. Scimmarella J, Gerard WA: The credentialing debate: On the outside of the house of emergency medicine looking in. Ann Emerg Med 1994;24:293-295 4. Hellstern RA: Point: Ethical emergency medicine group practice-An oxymoron? Ann Emerg Med 1994;23:1349-1350 5. Bullock C: And due process for all. Emerg Med News 1995; 17:1 6. Plantz SH: Group Practices Survey. Am J Emerg Med 1994;12: 610-611
7. Franaszek JB: Moving to solve our manpower crisis. Ann Emerg Med 1993;22:134-136 8. Chavinson E, Panacek EA, Plantz S: Employment opportunities for graduating EM residents. Enn Emerg Med 1997;30:412 9. Keller KL, Koenig WJ: Management of stress and prevention of burnout in emergency medicine physicians. Ann Emerg Med 1989; 18: 42-47 10. Gallery ME, Whitley TW, Klonis LK, et al: A study of occupational stress and depression among emergency physicians. Ann Emerg Med 1992;21:58-64 11. Doan-Wiggins L, Zun L, Cooper MA, et al: Practice satisfaction, occupational stress and attrition of emergency physicians. Acad Emerg Med 1995;2:556-563 12. American Academy of Emergency Medicine. Mission statement. Common Sense (newspaper of the AAEM). 1996;3:2 13. JCAHO Accreditation Manual for Hospitals. 1994. Sections MS 2.16.6, MS 3.3.2, and MS 3.3.3 14. Section 9.05. Code of ethics: Current opinions with annotations. Chicago, IL, American Medical Association (Council on Ethical and Judicial Affairs), 1994 15. Section 9.02. Code of medical ethics current opinions. Chicago, IL, American Medical Association (Council on Ethical and Judicial Affairs), 1994 16. ACEP Policy Statement: Agreements restricting the practice of emergency medicine. ACEP News August 1995:15 17. McNamara RM, Kelly JJ: Impact of an emergency medicine residency program on the quality of care in an urban community hospital emergency department. Ann Emerg Med 1992;21:528-533 18. Panacek EA, Pali M, Roland C: Practice patterns in an emergency department "fast track" setting: Comparison by training background. Acad Emerg Med 1996;3:436 (abstr) 19. Mower WR, Morgan MT: Effect of physician training on quality of emergency care. Ann Emerg Med 1996;27:134 (abstr)
A National Survey of Board-Certified Emergency Physicians: Quality of Care and Practice Structure Issues SCOTT H. PLANTZ, MD,* LANCE W. KREPLICK, MD,t EDWARD A. PANACEK, MD,::I:TEJAS MEHTA, MPH, MBA,§ JON ADLER, MD,II ROBERT M. McNAMARA, MD¶ The opinions and experiences of board-certified emergency physicians regarding employment structure and finances, professional society policies, and quality of patient care have never been formally studied. A survey questionnaire was sent to a random sample of 1,050 emergency physicians certified by the American Board of Emergency Medicine. The survey contained 29 multiple choice questions. Of the 1,050, 465 (44.3%) of the surveys were returned. Respondents averaged 13.5 years of emergency medicine practice, 83% were members of the American College of Emergency Physicians, and 44% were emergency medicine residency trained. Seventy-five percent felt they had been financially exploited by the emergencydepartment contract holder and 49% considered leavingtheir employer because of unfair business practices. Fifteen percent have been terminated without due process/peer review, and 11% have been forced to leave a position, move, or pay compensation because of noncompete clauses. The majority reported encountering instances of substandard emergency medical care, most commonly in settings with multihospital contract company coverage. The majority also believe their specialty societies should address issues of employment structure and quality of patient care standards. (Am J Emerg Med 1998;16:1-4. Copyright© 1998 by W.B. SaundersCompany) Although controversial for many years,1 emergency medicine practice issues have recently received increased attention. 2-5 These include concerns about financial relationships, employment arrangements, practice environment, and quality of care. Only one study, very limited in scope, 6 regarding the practice environment of emergency physicians has been published in the literature. More commonly, discussions regarding these issues have occurred in editorials and the From the *Department of Emergency Medicine, Chicago Medical School and Mt Sinai Medical Center, Chicago, IL; the tDepartment of Emergency Medicine, University of Illinois and Christ Hospital and Medical Center, Oak Lawn, IL; the :~Department of Emergency Medicine, UC Davis Medical Center, Sacramento, CA; the §University of Illinois College of Business, Chicago, IL; the IIDepartment of Emergency Medicine, Massachusetts General Hospital, Boston, MA; and the ¶Department of Emergency Medicine, Allegheny University of the Health Sciences, Philadelphia, PA. Manuscript received October 4, 1997; accepted November 4, 1997. Address reprint requests to Dr Plantz, Suite 103, 4450 Gulf BIvd, St Pete Beach, FL 33706. Key Words: Emergency physicians, survey, quality of care, group practice, politics. Copyright © 1998 by W.B. Saunders Company 0735-6757/98/1601-0001 $8.00/0
print 24 and television media, generally focusing on anecdotes and suffering from a lack of objective data. Although it is likely that issues of practice structure and politics within the specialty play a role in determining satisfaction with practice, physician well-being, and quality of care, the position of emergency physicians on these issues has not been formally investigated. The purpose of this study was to determine the opinions and quantitate the experiences of board-certified emergency physicians in some of these controversial areas.
MATERIALS AND METHODS A list of 10,500 diplomates of the American Board of Emergency Medicine (ABEM) was obtained from the American Board of Medical Specialties (ABMS) directory of certified emergency physicians. A computer randomization program was used to randomly select 10% (1,050) for the survey. The first mailing was in July, 1995. Second (October, 1995) and third (January, 1996) mailings were sent to nonrespondents. All responses received between July 1, 1995 and June 28, 1996 were included in the study. After receipt, all surveys were handled in an anonymous fashion such that the sender could not be identified. The survey consisted of 29 closed-ended questions. Five related to respondent background information and current employment status. Of the others, 2 questions related primarily to financial issues, 11 to professional society policies, 9 to practice structure and experience, and 2 to quality of care. All questions were multiple-choice with mutually exclusive answer categories. The majority of questions were framed in the form of a question, with three answer options. An example of such a question is the following: "Have you ever been forced to leave a position, move, or pay compensation because of a non-compete clause in your contract?" The potential answers were, "yes," "no," or "no opinion." The questions relating to quality of care had several subsections relating to background of the practitioner involved and the employer or practice setting. Survey responses were collated by question and, where appropriate, by category. This was performed by a nonphysician. Simple descriptive statistics were used to summarize responses. The survey study was deemed exempt from human subjects review as meeting exemption category 2 (45 CFR 46.101B).
RESULTS Four hundred sixty-five of 1,050 (44.3%) emergency physicians responded to the survey. Respondent emergency
2
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 16, Number 1 • January 1998
physicians' demographic information is listed in Table 1. The vast majority were American College of Emergency Physician (ACEP) members, and the most common employment setting was in democratic partnerships. Respondent demographics were similar to data for the entire group in the areas of emergency medicine residency training (44% v 48%, personal communication, ABEM) and ACEP membership (83% v 78%, personal communication, ACEP). The clear majority of respondents (78%) identified a democratic partnership as their preferred practice setting, followed by those preferring hospital employee status (13%). Only 4% preferred working in a sole proprietorship and 5% for a multihospital contract company (MHCC). Table 2 summarizes the responses to many of the questions relating to employment practice and financial issues. Not all respondents answered all questions. The number answering each question is indicated, and percentages in each answer category are taken from that number. A surprisingly large majority (75%) of respondents have felt financially exploited, at some point in their career, by the holder of the emergency department contract. Of these, the most common settings for the perceived exploitation were MHCC (29%), and sole proprietor (28%) employers. Ten percent felt financially exploited as hospital employees and 8% by democratic partnerships. Half the respondents felt exploited in terms of work schedule; again, the most common practice settings for this were sole proprietorships (19%) and MHCCs (17%). A significant number of respondents reported being terminated without "due process" (15%) or being forced to leave a position, move, or pay compensation because of a "non-compete" clause. Unfair business practices were considered so extreme by 49% that they considered leaving the employer. Several questions related to the role and policies of emergency medicine professional societies. Eighty-two percent responded that their society leadership should be elected in a democratic (one-member, one-vote) system. Eighty percent believed that "fellowship" status should not be offered to non-board-certified emergency physicians, and 55% indicated that only board-certified emergency physicians should be allowed full voting status. Sixty-seven percent responded that professional emergency medicine societies should develop standards for certifying emergency departments, and 77% thought societies should establish quality of care guidelines applicable to emergency medicine management organizations. Eighty-nine percent indicated a specialty society should lobby for due process/peer review for emergency physicians, and 63% indicated a specialty TABLE 1. Respondent Demographic Information Years of emergency medicine practice (average) Member of ACEP Member of AAEM Emergency medicine residency trained Current employment setting: Hospital employee Democratic partner group University faculty MHCC Sole proprietor contract Other
13.5 years 83% 29% 44% 18% 38% 7% 18% 10% 9%
TABLE 2. Responses to Employment Practice Questions
N* 1. Terminated without due process? 2. Forced to leave, move, or pay because of "noncompete" clause? 3. Considered leaving emergency medicine because of unfair business practices? 4. Job threatened by voicing "quality of care" concerns? 5. Job threatened by voicing equitable compensation concerns? 6. Felt financially exploited by emergency department contract holder? 7. Felt schedule was exploited by emergency department contract holder?
Yes
No
No Opinion
423 15% 85%
0%
423 11% 88%
1%
432 49% 47%
4%
448 23% 77%
NA
434 27% 73%
NA
465 75% 25%
NA
465 51% 49%
NA
*Number of respondents answering the question.
society should lobby for a cap on management fees. Fifty-eight percent of respondents believed that a specialty society should lobby to prohibit the buying and selling of emergency department contracts. Eighty-three percent of the respondents suggested that a specialty society should risk litigation to establish policy that discourages unfair treatment of emergency physicians. Two survey questions asked if the respondents had encountered substandard emergency care in their practice and, if they had, associated with which types of practitioners and employment structure settings. The responses are summarized in Table 3. Substandard care was most commonly perceived to be provided by physicians without certification TABLE 3. Responses to Quality of Care Questions N Practitioner type associated with perceived substandard care Emergency medicine boarded/eligible Other boarded/eligible Not boarded/eligible Moonlightingemergency medicine resident Moonlighting nonemergency medicine resident Practice settings associated with perceived substandard care Democratic partnership Sole proprietorship Hospital employee MHCC
None Rare* Occasional* Frequently*
416 10% 54%
29%
7%
411
25%
50%
22%
387 4% 10% 335 12% 29%
36% 43%
50% 16%
355
3%
7%
9%
36%
48%
292 21%
54%
19%
6%
295 11% 23% 266 15% 28% 309 6% 12%
42% 41% 32%
24% 16% 50%
*Rare = 1 to 2 times; occasional = 3 to 4 times; frequently = more than 4 times in career.
PLANTZ ET AL • EMERGENCY PHYSICIANS' SURVEY
in any specialty and by moonlighting non-emergency medicine residents, and was least often associated with emergency medicine boarded/eligible physicians. MHCC and sole proprietorship contract settings were reported most frequently as associated with substandard care. Twenty-three percent of respondents reported that they had been threatened or actually lost an employment position after voicing concerns about quality of care issues. Seventyseven percent of respondents favored legislation establishing standards for emergency staffing, such as a minimum of one board-certified emergency physician at all times in all level 1 and 2 trauma centers. Sixty-six percent favored legislation establishing minimum acceptable levels of training prior to working single coverage in any emergency department and 84% wanted emergency medicine professional societies to take the position that emergency medicine is best practiced by emergency medicine-certified physicians.
DISCUSSION Controversy is not new to emergency medicine, but increasingly, practice aspects have received attention. 2-7 No formal study of these issues has previously been published. As a result, much of the debate regarding the potential effects of different emergency physician employment structures, and other controversies, has lacked objective data. This study is the first attempt to quantitate emergency physician opinions and experiences in these areas. Nationally, corporate entities control an increasingly larger share of emergency services, s although our findings suggest emergency physicians have their best experiences in democratic partnerships and 78% would prefer to work in democratic groups. The vast majority (75%) of emergency physicians have at one point in their career felt financially exploited by the owner of the emergency department contract, most commonly those owned by sole proprietors and multihospital contract companies. Considering nearly half of our respondents have considered leaving their employer because of unfair business practices--and multiple reports indicate emergency medicine has a high attrition rate9-11--the impact of this issue on physician satisfaction and well-being warrants further scrutiny. We found that due process/peer review is very important to certified emergency physicians and 89% favored lobbying by specialty societies for due process/peer review for emergency physicians. However, it is unclear which entity (eg, hospital or group) would be expected to grant the due process. This survey did not examine the issue in detail. There does not appear to be a clear consensus by emergency medicine societies on this issue. 5,12Part of the reluctance by professional societies involves a concern that litigation might result from taking positions on these issues. Although 83% of the study respondents felt their specialty societies should risk litigation to address this issue, it is unclear if they are willing to pay for the potential costs, ie, with higher dues payments, etc. Given that both the American Medical Association (AMA) 13 and the JCAHO 14 strongly advocate due process/ peer review prior to physician termination, it is alarming that our study found that 15% of emergency physicians have
3
been terminated without appropriate due process/peer review. The AMA, 15 the American Academy of Emergency Medicine (AAEM), 12 and ACEP 16 all oppose the use of noncompete clauses in physician contracts, yet 11% of our respondents have had to leave a position, move, or pay compensation because of such a clause. Our results also suggest that many emergency physicians are not allowed to speak openly about perceived inequalities within their practice. About 25% of responding emergency physicians have experienced threats of termination after voicing complaints regarding issues of equitable compensation or scheduling. Perceptions of uneven quality of clinical care in emergency departments have received attention in the lay media and elsewhere. The experiences reported by the emergency physicians in our study seem to substantiate these concerns. Our respondents reported being aware of numerous instances of substandard emergency care, most commonly associated with physicians not boarded in any specialty or moonlighting (non-emergency medicine) residents. This view is supported by a limited body of literature that demonstrates board-certified emergency physicians provide better quality and more efficient care lv,~s and are preferred by emergency department nurses. 19 Contract companies, nonetheless, may have a financial incentive to hire non-boardcertified emergency physicians, including ones working in the field part-time, and continued expansion of these groups could detract from the quality of care provided. This observation was further supported by the survey finding that substandard care was most frequently reported when the contract was held by MHCCs. Compounding this issue was the fact that MHCCs were reported as the most likely employers to threaten or terminate a physician for voicing concerns on quality of care issues. Perhaps for this reason, the vast majority of respondents believed minimum standards should be established for single coverage emergency department staffing in general, and particularly stringent requirements for emergency department staffing at level I and II trauma centers. This study has limitations that may affect interpretation of the results. The overall response rate is lower than the goal generally desired for such surveys. However, it is similar to the response rates often obtained in survey studies involving large numbers of emergency physicians. 6,11Additionally, the respondents appear to be generally representative of the overall group in the baseline demographic areas compared. Second, this survey only involved board-certified emergency physicians and the results should not necessarily be extrapolated to all physicians practicing in the emergency department. However, a prior, smaller survey was done using a random sample of the AMA/PDR list of physicians primarily practicing emergency medicine. 16 That list included a large number of non-board-certified emergency physicians. Some of the questions covered the same emergency medicine practice issues and the results were quite similar. Finally, these survey results represent physician self-reporting and opinion. There was no independent or objective confirmation of actual exploitative practices, termination, lack of due process, or substandard care.
4
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 16, Number 1 • January 1998
C0NCLUSl0NS As the first large survey to address many controversial practice issues in emergency medicine, this study found physician exploitation is perceived to be very high and terminations without due process and conflicts over "noncompete" clauses are common. A democratic partnership is the employment structure clearly preferred by a large majority of the responding board-certified emergency physicians. The majority want their professional specialty societies to address issues of employment arrangements and patient care standards. Concerns about an association between substandard clinical care and certain categories of practitioners, or employment structures, warrant further investigation.
REFERENCES 1. Hellstern RA: National contract groups. J Am Coil Emerg Phys 1979;8:493-495 2. Danzl DF: Restrictive covenants: What would they have us teach? Academic News and Views (ACEP Publications). 1994:4-5 3. Scimmarella J, Gerard WA: The credentialing debate: On the outside of the house of emergency medicine looking in. Ann Emerg Med 1994;24:293-295 4. Hellstern RA: Point: Ethical emergency medicine group practice-An oxymoron? Ann Emerg Med 1994;23:1349-1350 5. Bullock C: And due process for all. Emerg Med News 1995; 17:1 6. Plantz SH: Group Practices Survey. Am J Emerg Med 1994;12: 610-611
7. Franaszek JB: Moving to solve our manpower crisis. Ann Emerg Med 1993;22:134-136 8. Chavinson E, Panacek EA, Plantz S: Employment opportunities for graduating EM residents. Enn Emerg Med 1997;30:412 9. Keller KL, Koenig WJ: Management of stress and prevention of burnout in emergency medicine physicians. Ann Emerg Med 1989; 18: 42-47 10. Gallery ME, Whitley TW, Klonis LK, et al: A study of occupational stress and depression among emergency physicians. Ann Emerg Med 1992;21:58-64 11. Doan-Wiggins L, Zun L, Cooper MA, et al: Practice satisfaction, occupational stress and attrition of emergency physicians. Acad Emerg Med 1995;2:556-563 12. American Academy of Emergency Medicine. Mission statement. Common Sense (newspaper of the AAEM). 1996;3:2 13. JCAHO Accreditation Manual for Hospitals. 1994. Sections MS 2.16.6, MS 3.3.2, and MS 3.3.3 14. Section 9.05. Code of ethics: Current opinions with annotations. Chicago, IL, American Medical Association (Council on Ethical and Judicial Affairs), 1994 15. Section 9.02. Code of medical ethics current opinions. Chicago, IL, American Medical Association (Council on Ethical and Judicial Affairs), 1994 16. ACEP Policy Statement: Agreements restricting the practice of emergency medicine. ACEP News August 1995:15 17. McNamara RM, Kelly JJ: Impact of an emergency medicine residency program on the quality of care in an urban community hospital emergency department. Ann Emerg Med 1992;21:528-533 18. Panacek EA, Pali M, Roland C: Practice patterns in an emergency department "fast track" setting: Comparison by training background. Acad Emerg Med 1996;3:436 (abstr) 19. Mower WR, Morgan MT: Effect of physician training on quality of emergency care. Ann Emerg Med 1996;27:134 (abstr)