October 29, 2021

ACEP President Dr. Gillian Schmitz Addresses the 2021 ACEP Council

In her address to the ACEP Council on Oct. 24, 2021, ACEP President Dr. Gillian Schmitz outlined her vision and approach to her year as the College's leader. She talks about unity, a new strategic plan to guide ACEP into the future, workforce issues to tackle and emphasizing transparency around various employer models and their practices.

Here's the full transcript:

Last year was a difficult year for so many reasons. We all felt varying levels of fear, anxiety, and uncertainty. A year later, those haven't gone away. We're tired. We're sometimes angry at our patients who don't believe in the vaccine or us. We're frustrated at our family, our neighbors, our colleagues, because we have different political views. And we wonder how will this country ever get it right?

We even had heated discussions amongst ourselves, on whether we should be here today in person or whether we should meet virtually knowing that we all want to be together, but respecting our differences and our comfort levels with the virus. What's safe and what is it? What's good optics versus bad optics? And from whose point of view? How do you represent an organization with such diverse views? How do you bring together a college, a specialty, a country who is so deeply divided?

How do you instill hope and optimism when we're surrounded by exhaustion and burnout? I look to past leaders to see how they led in turbulent times. What would Abraham Lincoln can do? More importantly, what would Ted Lasso do?

All right, by show of hands, how many people watch Ted Lasso? Woohoo! So, I love this show, and this is going to be my style of leadership because I think this is more than just soccer. This is about leadership. It's about bringing together and supporting a team. And it's about kindness. It's about finding that unity of bringing people together to really believe a mission that is bigger than any of us individually. And I think Ted Lasso would say that we're not the Democratic College of Emergency Physicians and we're not the Republican College of Emergency Physicians. We are the American College of Emergency Physicians.

It was amazing to slowly return to normal life this summer and to visit some of the chapters. We continue to move forward, even in times of uncertainty and polarization, to do what we believe is right in our minds, in our hearts, and in the best interest of those who we are charged to protect and represent. We are hands down and without question, the leading advocates for our patients and our specialty, even when we're up against what seems like insurmountable odds.

I know people feel demoralized. I know many of us feel right now that things have never been worse for emergency physicians, but the reality is we've beaten these odds before. The fact that we're even here when emergency medicine didn't even exist 50 years ago, except in the corner basement of a hospital with leaky exposed pipes, is a testimony to that. We stand today on the shoulders of giants, on the mavericks, the pioneers, the scrappy fighters who founded our specialty, who fought against those who didn't want us to be here. Who said that we deserve to have our specialty. We deserve to have a chance. They saw a challenge and they fought together and they won, just as we need to come together today and fight for our specialty.

Do we have challenges ahead of us? We sure do. Are there going to be times we disagree on how to approach those? Absolutely. But will we find common ground? I believe we will. Can we put aside our personal politics and differing opinions to come together as a specialty, to listen to one another, to try and see things from someone else's perspective? Will we seek to understand before we demand to be understood—for the greater good of our patients and our specialty? I say, yes. Yes, we will.

We cannot solve the challenges of our time unless we solve them together. We may have different stories, different politics, different employers, but we hold common hopes. We all want to move in the same direction, toward a better future.

I have spent the last year intently listening to my fellow board members, friends, colleagues, staff, and even some of my biggest critics and some antagonistic individuals on social media. For those of you who attended LAC, we had a panel of congressmen, and they said that success is defined by getting beat up on both sides of the issues on social media, because it means that you're working to finding a fair compromise. Well, if success is defined by taking some punches on social media, then by all means I am doing an outstanding job.

But there are some things that I'm going to do a little bit differently as ACEP president. I'm going to ask us to get into some difficult conversations, things that are even controversial. But I believe that we can disagree without being disagreeable. We can take those different opinions and approaches to make us stronger, but we have to be willing to listen to one another.

So, what are some of those changes?

Number one: What is our mission? Why does ACEP exist? Over the last several months, the board has undergone an intense strategic planning project. Our historical mission has been to advocate for the highest quality care and advocate for emergency physicians, the patients, and the public. But what if those interests don't always align? For years, we have been torn, trying to represent both the specialty and our members. And I think that sometimes by trying to advocate for physicians, patients, and the public, we have become less effective. Our message can sometimes get diluted, and it may resonate less with those members who feel that we no longer represent their interests.

I believe we chose to become emergency physicians to help patients, but we joined ACEP because we wanted someone to represent us, our interests and our future. I believe our name is the American College of Emergency Physicians. That's not to say that patients are not important and at the center of everything that we do, but every parent and grandparent who has ever traveled on an airplane knows that the first thing the flight attendants tells us is to put our own mask on first.

We can't help patients effectively if we're not focused on protecting our own wellbeing and future. As a Board, and as your President, we support this. We believe this. We believe in you, and we're making a strategic pivot to ensure that professional and personal fulfillment of emergency physicians is at the core of everything that we do.

Number two, workforce. I applaud ACEP and our partnering organizations for having the vision back in 2017 to study our workforce. Many of you may not actually know this, but at that time, there were a number of people who thought we would never have enough emergency physicians, who told us this was a waste of time and money to study this, but that data turned out to be critically important. And it gave us very valuable time to develop a framework, to course-correct, and to work together to change the trajectory of our future.

And we're already seeing the results of some of this. This is relatively hot off the press. This came out last week from ERAS, that market forces will influence the number of students who apply to emergency medicine and those who attrition out of the workforce. Applicants for emergency medicine are down about 10 percent per program since 2019.

We're next to radiology oncology, who was also supposedly having a surplus. Now, the overall number of applicants is not down that much. The denominator is diluted a little bit because of the number of increased programs, but it is the first time that we are down with a number of applicants. I personally think this is a good thing because it means that markets are responding in a predictable pattern to match supply where it is needed the most. It'll be critically important that we continue to watch these dynamic changes to our workforce closely over the next decade.

Private equity, consolidation healthcare, and corporate ownership and medicine. Everyone, take a deep breath. I believe these are some difficult topics. And historically it has been felt that ACEP is afraid to tackle these issues – that it's the elephant in the room. So let's start talking about them. But if we talk about them, let's speak about it with facts and data and not rumors and misinformation, or we’re no better than the people who spread rumors and untruth about vaccine and ivermectin.

And it all comes down to this. The government has changed how we are reimbursed. We are moving away from fee for service to being paid for value. Aside from cutting costs, one of the easiest way for corporations, hospitals, health systems to achieve this is to create economies of scale and to create better leverage through having larger portions of market share. And this was a completely predictable pattern of what we've seen across all of healthcare. Hospitals have merged and are now health systems.

Insurance companies. There used to be dozens and dozens of them. Now, for all intents and purposes, there's three or four. And in many markets, there may be only one. Physicians, for the first time, are more likely to be employed. They have less ownership over their practices. And as a result, we've become increasingly divorced from how we're reimbursed. And it has become essentially a tug of war between the insurers on one side and the physicians on the other, trying to negotiate fair reimbursement. And both sides want that leverage, that market power to be able to command higher rates.

Which begs the question: Is bigger better? And I believe this is the question that has really divided our specialty. And people have very strong opinions on either way. And this is why we have all been challenged to try and answer the question, how has this consolidation of practice impacted cost? How has it impacted quality? How has it impacted physician autonomy?

And we don't know the answer, and it's very frustrating because we really want to know. And there's a lot of people who think they know, but this is what actually has been studied. The AMA, which has significantly more size and resources, tried to grasp this. And after much research, they concluded that there is little peer-reviewed evidence regarding the impact of corporate investors on physicians, physician autonomy, patients, or healthcare prices. Although there was some anecdotal information based on specialties, there was not sufficient data to draw meaningful or actionable conclusions.

So then we thought, well, maybe Congress – if Congress has access to things that we can't get access to, surely MedPAC can come up with an answer. And in July, MedPAC released their report and MedPAC's report to Congress said that there was incomplete data on corporate transactions involving physician practices. And in fact, this lack of transparency is a significant impediment to determining the impact of corporate investors on physicians, patients, and the healthcare marketplace. And they noted that evidence were acquired not just by private equity, but by hospitals, health systems, academic medical centers, and physician groups and insurers. So this is a complex, changing, dynamic problem.

And then ACEP was asked to study it. And we looked and worked with an outside vendor who looked at this and spent a significant amount of time looking at their databases. And they came back also empty handed and said, frankly, the data doesn't exist.

Well, we're not giving up there. I am determined to find some answer to this. And so, what can we do? And where can we go to start getting the answers that critically impact our future?

So we started by doing, as part of the workforce study, Ed Salzberg surveyed emergency physicians. And many of you have seen this graph on social media, in different forums that showed a subjective qualitative survey that physicians had a very negative impact on what they felt was the role of increasing corporation and roles on large organizations. And I think we would be remiss to ignore this. We have to take this seriously. And this stood out in some of the data, that people purely felt that this was concerning and impacted job satisfaction in a negative way. However, this was subjective. And half of the physicians who answered this survey had never worked for a large corporate group.

The question that came after that, which has not been shared as widely on social media, asked the same participants, how do you feel about your job? And 80 percent said they were satisfied or even very satisfied. Only 5 percent said they were very dissatisfied, and there was no statistical difference between those who worked for large corporate groups, those who worked for small democratic groups, and those who worked for academic or military.

They asked the same physicians, well, how do you feel about your level of compensation? Almost 90 percent felt that they were satisfied or very satisfied with their level of compensation. Again, less than 5 percent felt very dissatisfied. And so it seems even with our own data, it's a little conflicting that people are clearly upset for a number of different reasons, but they still overall like their jobs and they feel they're being compensated fairly. So how do we end up with all of this data, and what do we do with it?

I think we have to acknowledge that there is a lot of misunderstanding in definitions, and part of it is that we don't have good definitions. One of the first things I was taught as a researcher is that you have to have clearly-defined variables in order to make comparisons. So, what is a small group? Is it 20 physicians? Is it 50 physicians? What's a large group – 1,000? 2,000? Is it based on the number of physicians they employ, the number of contracts they hold or how many states they're represented in? Even amongst corporate groups, they're not all the same. Some have physician ownership and some don't. Some have private equity and others don't. Just because a group is democratic doesn't mean that it's actually democratic or has open books. And just because a group is academic doesn't mean that it necessarily has due process or transparency in billing. And private equity is not synonymous with corporate management groups, right? Some larger groups don't have private equity. And in fact, there are a number of academic groups like Mayo Clinic, Indiana University that also have private equity investment.

So, these are really important questions. And we're trying to get to the impact of what this is, but I think I have to impress upon you that this isn't as easy as many people think it is. I wish it was as easy of having two easy buckets of saying good and bad. But the reality is our current practice is much more complex than that. And bad contracting behaviors are bad contracting behaviors. They are not unique to one employment model. If we're going to scrutinize how groups practice, let's pull back the curtain on everyone and apply the same criteria and level of scrutiny on all practices.

Another reason it's been so hard to answer these important questions is that there is so little transparency in healthcare. So let's start making things more transparent.

ACEP has always advocated for these principles and rights for emergency physicians. We've had policy statements on due process, on transparency and billing and a number of educational resources to help our members. But I'm hearing that's not an enough, and I'm hearing that loudly and clearly.

So what else can we do? We've previously reintroduced legislation on due process and we'll be working with Representative Ruiz to reintroduce legislation that will advocate for due process. We can create a new conference that will be starting in November of next year to teach emergency physicians how to go out and start their own group, how to compete for contracts. We can offer legal counseling to our members to review their job offers and contracts through our wellness assistance program. We can create a checklist that shines a bright light of transparency on any group who wants to advertise or exhibit with ACEP. And we can explore legislative and regulatory pathways to help enforce that all groups are held accountable to fair business practices.

Every emergency physician deserves the minimum amount of information to make the best decision they can for their lives, their families, and their careers.

In addition to the margarita machine, I do want to give a shout out to NEMPAC for the amazing opportunities that they offer. On the picture here on the right is me and Dr. Sontag with Representative Tony Gonzalez. This was at my house. We got to interview a candidate for Congress who then got elected. I've had a number of conversations with him subsequently, and we're now on a first name basis and he will sometimes call me for advice on various issues and help us have a direct conduit to Washington. We want to advocate for things that we want to push through. This is really the power of NEMPAC, the ability to meet with people like Representative Greg Murphy in the top with Dr. Casaletto and myself, to help advocate for things on a national level, because this is how change gets done. It is through those personal relationships, and NEMPAC is really our best tool to help get our voice to Washington.

I also want to give a shout out to EMF. EMF helped get my very first research grant. It helped launch my academic career, and this is a valuable way for us to take those questions where we need data, like how are outcomes of patients who are treated by nurse practitioners different than outcomes by treated by emergency physicians? That's an important data point that we need for our advocacy efforts, but that data doesn't exist yet. And EMF is funding research grants to actually help answer those important questions to guide our research.

So going back to my Ted Lasso analogy, I want to acknowledge that we have a tough road ahead, but I know that our team and college is even stronger. This is a scary time. I know the emotions people are feeling, but it is going to be okay.

We're going to get through this year and next year, and whatever else unexpected gets thrown our way, because dealing with chaos and the unknown in a broken system is what we do every day on shift. And we're pretty damn good at it. I am confident we will come out of this even stronger on the other end.

And I want to end on a note of gratitude. Can I ask my husband back there in the middle to stand up? That devastatingly handsome man in the back there is an orthopedic surgeon, the best father you can ever imagine, and an incredibly dedicated and supportive spouse. Many of you know that I wouldn't be here today if he had not really encouraged me and pushed me to run for this position. He has been a huge champion and advocate and really a supporter of women in leadership. And he helped me overcome my own imposter syndrome to grow into something bigger than I ever was before. I don't know what I would be without you. I love you so much. And thank you for everything that you do.

Thank you to our staff who have worked under insane conditions and a constantly changing landscape to innovate, adapt, and advance the College. Thank you to Mrs. Sedory for joining us in the middle of a pandemic, for your vision and fresh perspective on the operations and leadership of our College. Thank you to Mark for your leadership. And Dr. Rosenberg, if you want to start making your way down here, I've got a few other words for you.

Thank you to my Board, the work-hard, play-hard crazy group that keeps me on my toes, that have been bold servant leaders, nuanced thinkers, and challengers of the status quo. You challenge me to be a better physician, a better person, and a better wordsmithing task force, or WTF, champion.

And thank you to the Council and membership for your dedication, persistence, and resilience in what has been an incredibly difficult year. Remember that what you do has purpose. What you do saves lives, inspires dreams, speaks for those who have no voice, challenges our healthcare system to thrive, and pushes our specialty to constantly adapt and evolve. You are my heroes. You are my family. And I am incredibly proud to serve you and this College. Thank you.

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