Editor's Forum

Building Trust Through Integrity

"It's against my beliefs." "Personal choice." "I know what some of my friends went through and I decided not to."

These are the vague, dismissive statements I hear when I ask my patients why they didn't get vaccinated against COVID-19. In truth, the reasons so many of our patients deferred the vaccine are myriad and diverse. For some, the reason was a mistrust of physicians and our health care system, which has become more of a market than a system with every passing year.

I can't say I blame them. Through the 2000s, my patients saw highly profitable "pill mill" pain clinics raking in the cash across Appalachia only to see their loved ones with back pain from manual labor jobs turn to street opioids when regulations tightened, clinics closed, and their oxycodone supply dwindled. Older patients may even remember when the U.S. Narcotic Farm, a prison for the rehabilitation of incarcerated people with drug addiction in Lexington, Ky., was exposed in the 1970s for the torturous experimentation physicians and scientists had imposed upon the incarcerated. For decades, these physicians had bribed the incarcerated with heroin to participate in experiments. They would push vulnerable people to the most brutal depths of withdrawal in order to document their deterioration and determine whether withdrawal could be fatal.

These atrocities and others like them (the Tuskegee untreated syphilis study, surgical experimentation on Black women throughout slavery and the Jim Crow era, and the lack of equitable healthcare provided to our patients who are incarcerated that continues to this day) have been committed by physicians who tell themselves they serve a greater good. Though we cannot directly compare the aforementioned tragedies with the conflicts we face in EM today, we are confronting an ethical dilemma that has been brewing for years. It impacts patients' health while business executives and shareholders, far removed from the patients they impact, stand to make millions: the corporatization of emergency medicine.

The role of contract management groups backed by enormous private equity companies in the hiring, firing, and medical practice of EM physicians has become increasingly scrutinized. Little data is available to quantify the impact CMGs have on quality of care in the emergency department, but in a recent online survey of EMRA members many of you raised concerns that overreaching corporate interests by non-physicians may prioritize profits over patients.  In the wake of the controversial predicted surplus of over 7,000 EM physicians by 2030, EMRA is joining this conversation. Based on member surveys, online member discussions, and meetings of the Board of Directors (composed of EM residents and fellows like myself) EMRA President Dr. Angela Cai has released EMRA’s EM workforce statement. Reproduced over the following pages, this living document is only one step in EMRA’s journey through the rapidly changing world of EM administration.

As Editor-in-Chief of EM Resident, I also must acknowledge the publication’s advertising relationship with CMGs. The other residents and myself who comprise the EMRA Board of Directors are perceptive to your concerns regarding these relationships, and also cognizant of the fact that many of you will go on to staff CMG-owned EDs. EM Resident will continue to examine our corporate relationships and serve as a platform for authentic discussion on this issue. I always welcome your letters to the editor on topics like this, sent to the email below.

What is most important to us as physicians must always be the patient. This job does not exist for us to earn a salary. It certainly does not exist for shareholders to turn a profit. This job exists to help people who are suffering. Centering that humanity and compassion in the decisions we make is essential to making the right decisions for our patients and maintaining the public’s trust in our integrity. Our response to the difficult job market must be patient-centered. Reducing residency spots to alleviate saturated job markets in attractive cities is not patient-centered. On the other hand, enforcing the requirements of residency accreditation produces better physicians that meet our standards for patient care. Advocating for state and federal funding for emergency physician coverage in rural, lower-volume EDs would also alleviate urban job market saturation while better serving our rural patients currently seen by non-physicians and non-EM-trained physicians.

In the changes that we make in medicine, and the ones we passively allow to happen, it is our responsibility to constantly evaluate whether we are building a compassionate healthcare system or one driven by profit. We are trusting this system to heal the people we love most. We are trusting it to also heal the people who have no one else to care for them at all.

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