GSACEP Lecture Series: The History and Future of Emergency Medicine by Dr Gillian Schmitz

ACEP President and GSACEP member Dr. Gillian Schmitz shares how we evolved to this current time in emergency medicine and priorities going forward as our specialty continues to serve patients and our nation.

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Transcript

Gillian Schmitz: 1:15

All right. Well, good morning, everyone. I thought we'd talk a little bit about sort of the history and future of Emergency Medicine. This is a time of a lot of anxiety and concern about what's happening with our specialty. And I think a lot of what we're talking about the issues today are not new. In fact, we've been doing this for kind of a long time. And one of the best kind of learners of the future is understanding where we started, and kind of how did we get here to many of the things are affecting us today. Someone sent me a copy of this. And I thought this was really interesting that emergency medicine was on the cover of Time Magazine. But I want you to look at that top left corner there, the date there is May 1980. And the time at that time was hospitals are facing critical conditions, too many patients too little money, staff at risk of burning out nursing shortages, non paying patients drug violence, of this is a crisis, we're never going to recover. So the more things change, the more things stay the same. We've been through this before. And this is part of a course of what emergency medicine has gone through. But yet we're resilient, and we bounce back. So it's interesting when you think about medicine, how did this start? So back in the 1700s, if you had appendicitis, the doctor came to your house, they actually operated like in your bed, there was no hospital, the doctor had their little black bag, and they came to your house, if you had money. If you didn't have money, there really was no health care system. There was sort of what they call the ALMS houses. And the very first hospitals began opening up in 1736. There were two of them charity, and shortly after that it was Bellevue. And for all intents and purposes, these were sort of homeless shelters, they dealt much more with social determinants of health than they did healthcare. In fact, infection was rampant in many of the very first hospitals. And then around the turn of the century, we saw the sharp incline and the number of hospitals. Well, what happened, we had a huge influx of funding from the government through it was called the hill Burton act. And at the same time, we began building roads and highways and people were moving away from the rural areas and into these big cities. We saw an influx of money from Medicare. So finally, the government was paying for people who were 65 and older, who had other comorbid diseases. And technology was changing, right, the very first CT scans, I think it had one cut, right, you either had a brain yes or no, that was like the limit of technology. But technology wasn't fitting so nicely in those little black bags anymore. And so people started leaving their hospitals or their clinics, and going to the hospital to get their emergency care. But the hospitals weren't ready for them yet. People didn't have an emergency room. And the very first emergency rooms were literally called the pit. Because we were in the basement with these leaky exposed pipes that were gurneys that weren't even necessarily private beds. You had nurses who would come out, you would ring a bell. In fact, if any of you been to Andrews, there is still a bell that you rang to get service to see if they could even take care of you. And if the nurse thought you had a head bleed, if they didn't have a neurosurgeon around, they would just say I'm sorry, we can't take care of you have to go somewhere else without having any kind of policy or system of where they needed to go. And medical students or interns, were the ones taking care of potentially the sickest amount of patients, it was deemed, quote, a great place to learn. And there was no supervision. It was sort of the wild west of who was taking care of emergency patients, until some people in Jim Mills was one of them. So maybe we could do this differently. What if we gave up our clinics, our hours and just focused on one specialty of taking care of the unknown, the acute undiagnosed patient? And people thought they were crazy. Of Why would anyone want to take care of anyone, anywhere, anytime. And many people didn't want us to be in that space. In fact, the surgeons push back really hard that we were quote the enemy, right. Nobody wanted emergency medicine. It was a turf battle of who was going to be in this space. And people like Peter Rosen, who I worked with in San Diego, and Judy tintinalli. In North Carolina, by the way, it's very intimidating, working on your chair wrote the book of Emergency Medicine and she would chase you around the emergency department like Didn't you read my chapter? It's like, ma'am, I haven't gotten to that page yet. And so we went to the ABMS, the American Board of Medical Society, and we made our plea that emergency medicine should be its own specialty. Anyone know what the results of that first vote were? We lost and we lost really badly. 100 to six was the first vote if people were voting against emergency medicine being recognized specialty. They said we didn't have a unique body of knowledge that we were not a different specialty, that we were glorified triage doctors. And so we had to go back to the drawing board. We had to create research we had to really get into the politics of medicine and fight for our specialty and we Did and after many years of going back of renegotiating we path in 1979, we became the 23rd recognized specialty in the house of medicine.

Unknown: 6:11

So since that time ASAP has done a number of workforce studies of looking at well, now that we have a specialty now that we're finally recognized, how many emergency physicians do we need, and when we found over time, is that the number of EDs have slowly decreased, although I put an asterisk because it does not include freestanding emergency departments. But you can see that the number of residencies has grown precipitously, really over the last 20 years in between 1999 and 2009. So in just that 10 years, there were only five new residencies. But look at the growth, it was almost a 50% growth of the number of residents per program over that time. And that was going because we were told, and we still thought and do today that we don't have enough physicians. But how many emergency physicians do we need? So if we look at these growth and programs we've seen between even 2015 And today, there's been a 30% increase in the number of emergency medicine residency programs, that is a huge increase. And it's going to be tough to keep up with that supply. And that's what caused these initial questions of, we know, we don't have enough doctors if we look at all specialties, but how many emergency physicians do we have? And on top of that the workforce is changing. And 20% of IDI visits are now seen by pas and nurse practitioners. And so we need to kind of look at our own workforce and see how many emergency physicians do we have today. So this was published in Annals and in 2020, there were almost 70,000 emergency physicians, they did not include residents as being clinically active, so only 50,000 clinically active, but there's a subset there are people who are practicing emergency medicine are still in the workforce, but they're not working clinically. And I think that's an important point I'm going to come back to, but over 70% of us are now a BIM residency trained board certified. And over 80% are em trained, so their board eligible but not board certified yet? That's insane. I remember when I was training, only half of Emergency Physicians were residency trained. So this is a huge shift of where we are evolving as a specialty and a great way. Today, there's almost 280 residency programs. We're about 28% women, which is sort of plateauing or even decreasing where we were a couple of years ago, and almost all of us practice in urban or suburban areas. And so last year, we did a workforce report to look at those projections. And they were exactly that there are projections. Whenever you do a workforce study, it's based on a number of assumptions of how quickly are we growing? What is the attrition rate out of the workforce, nobody could have predicted when we started this study in 2018, that we were going to have a massive pandemic that would affect people. But based on those projections, they said, if we continue at this rapid growth rate, if we don't somehow change that supply demand, we may have about 8000 More emergency physicians than we have jobs by 2030. And that caused a lot of concern. So where's that growth coming from? Well, part of it on that left side there is is the number of em actual positions. So the number of programs on the right side there has grown by about 15%. But the bigger issue is that residency is not only are growing in number, but they're growing in size. So where they used to have six residents, now they're graduating eight, or 10, or 12, and people are expanding their complement. So both of those things are contributing to the increase in supply. If you look at how big is emergency medicine, the median is 32. But we now have several emergency medicine residency is that have more than 100 residents in their class? Is that a residency or is that a small army, right that I can't even remember, like 30 people's names much less than you get much bigger. And so this is a very difficult question for us to answer. But how do we police this? How do we control our own growth and do it in a responsible manner? Well, much of what we talked about yesterday, is that this is driven by dollars. It's driven by funding, and GME is what pays for the majority of spots. And then they froze the cap at a certain point in time. They said we're not going to pay for this anymore. But yet we kept finding ways to pay for it because it was profitable to start a residency. And the cap only occurred for programs who had a previously approved program. So if you're a quote, Virgin hospital, you've never had GME, right, your Baptist Hospital down the street, you could just start a residency program. And when you do you have five years to really maximize your cap. And in some states, you get not only national kind of federal funding, you get state matching funds as well. So it can be very profitable. Unlike orthopedic surgery, for instance, and I pick on them because my husband's an orthopedist, it's pretty hard to start an ortho program, because they have a lot of sub specialty cases of certain oncology cases that they have to have. For emergency medicine. It's pretty easy honestly, to start a program right. Every hospital already has an emergency department. Unlike other specialties, we can predict how many Chest Pain How many belly pains we have coming in. And so we're looking at how do we change that and how do we make it harder? And who is starting residency programs? It's really everybody. It's not necessarily Just corporate for profit, it is for profit. It is nonprofit, it is public hospitals, everyone is getting into this business, because it helps support the emergency department helps with funding. And when we look at the pie, what makes emergency medicine different is that 70% of our patients don't pay the cost of care. No other specialty has that we are the only ones that have the EMTALA mandate. And so unlike everybody else, we can't turn people away, we wouldn't want to turn people away. But what other businesses could keep their doors open if 70% of their customers didn't pay for their service. And so it's putting a real strain on the health care system and on emergency departments. One of the things I think we heard this year, people were concerned about the civilian match of what what happened and people are freaking out. And this is mass exodus of students out of the specialty and it's not, what I want to point out here is that roughly the number of applicants is about the same as where we've been on par. This data was taken from sort of the mid match season, so kind of December and reflects the previous application cycle. So we saw kind of a bump in 2021. And that was in December of 2020. Well, what was happening in December of 2020, we were the healthcare heroes, everyone was banging pots and pans, a workforce report hadn't come out. So we saw this kind of unusual surge in the number of people who were applying to emergency medicine. So yes, if you're only looking at one year, there was a notable dip in the number of applicants. But looking at one year is not really reflective, because that one year was really an abnormality. If you look over time, and really since 2017, we're about on par, we had almost the same amount of applicants as we have always had. And in fact, this year, we had more people applying to emergency medicine than we did in 2019. So it's not that the number of students are not applying to emergency medicine is that we're offering too many spots, and that we're growing too fast. And this was what everyone was panicking about is unfilled, right? Because it's been unprecedented that emergency medicine wouldn't fill its spots. But you can imagine if you have the same amount of applicants applying to emergency medicine, or even a little bit less, but all of a sudden you've added 80 new spots to the match, you're gonna have more spots that are unfilled. A third of the programmers who didn't fill were in Michigan, a third were in Florida or in Texas. And those happen to be states where we were growing at a rate that was probably unsustainable. So to me, this is actually good news. This is a wake up call, this is exactly what we needed to happen to help the market forces correct to say, maybe we don't need to add more residency programs in Florida and Texas and Michigan, maybe we're good for a little bit. But people needed to see this to be able to correct those things and adjust. This shows kind of the number of applicants over time, the purple line is the number of applicants and the green is the number of available positions. So you can see in 2011, only half of people who apply to emergency medicine matched in emergency medicine. So the good news is we have way more applicants, we always have the number of spots. And we continue to be one of the most competitive specialties in the house of medicine. But over time, if that purple line drops, right, if the number of applicants dropped by the number of positions go up, you're going to come to a point where we become less competitive. And that's what we don't want to happen, we want to recruit the best and the brightest. And so our message has got to be that emergency medicine is very much the best specialty to go into. And we don't want to scare away our most competitive applicants. So what is ASAP doing to address this? So we've kind of coined the phrase, the five pillars. And these are things that we're doing to address really looking at those gaps in supply and demand. So pillar number one is looking at how do we raise the bar? If emergency medicine is too easy to start? How do we make it harder? It'd be great if you could just put a moratorium on the number of residency programs and say we're just going to stop. But you can't do that. Unfortunately, that's a big anti trust No, no. But we can raise the bar and standards, which would make it a little harder to create a residency program. So we've been meeting every two weeks with all of the different em organizations to talk about what is the right number of procedures? Anyone know how many intubations you'd have to do to graduate Emergency Medicine Residency? Yeah, but 30 If it's 35, and a third of them can be done on a mannequin. Right? How much does a mannequin like intubating someone in real life? Well of these mannequins are pretty good, I have to say, but maybe there's data to show that that number needs to be significantly higher. And actually, anesthesia has looked at this. And they said, even in a controlled airway, the number from their data of what you need to be competent was 70. So maybe we need to actually use data as opposed to 30 Sounds like a good number, which was kind of a back of a napkin math, to make it a little bit more difficult. And maybe for things that are life saving, like intubations or chest tube, maybe those needs to be done on a live patient and not just as a mannequin to be able to ensure that you're getting enough critical care and recitations to count toward training in emergency medicine. And do we need to redefine what a resuscitation is right now? What sort of nebbia That's right, we have to do X amount of trauma resuscitation or X amount of medical resuscitations. But some people are just giving an Albuterol inhaler and steroids in the counting that as a medical resuscitation, I don't think that was what it was meant to be. So maybe we need to be a little bit more defined about what our critical care is. But I'm sensitive to the fact especially the military, that our acuity tends to be a little bit lower, right? We don't want to hurt our own programs. So how do we balance that? For some of the recitations we have included live pig models, so that many of our pig labs that we're doing in residency would count toward that training. The point is, that has to be something that actually gets your hands dirty, you can't just do everything on a mannequin, some of them like cracks, we're going to have to do on mannequins, but looking at some of the more critical care of making sure we have enough patient encounters to make sure we're actually training to the best efficiency going forward. And we're looking at scaling programs. So if you have 100 residents in your program, how many patients? Are they actually seeing how many core faculty do you actually have? Are we having enough of a ratio where they're getting not just the clinical time, but that right amount of mentorship? So these are all things that we will be proposing to the ACGME. The ACGME is kind of the overarching body that has the final say, it is made up of people who are not emergency physicians, they have a lot of questions about how we do things, because we do things very differently. Our whole specialty operates very differently than other things. So they start to dive in on this next month. And we'll be looking and picking apart all of our requirements to see how this is going to change. We're looking at ensuring that business interests do not supersede education or patient care. And these events, some very difficult conversations. But I've met with all of those hospitals that were on that list that have opened residencies and said, Please stop. We're good. And that's not an easy conversation. But many of them have, we're going off older data, which said, we don't have enough doctors. And that's true what we heard yesterday, there's a huge nursing shortage. There's overall a huge physician shortage. When we look at our sub specialty on if you flip to page 58 of their report. For emergency medicine, we're kind of getting to the point where we're oversaturated. And many of them have come back and said, Well, we hear what you're saying. And we're listening to you and we're responding to your feedback. And this is the power that ASAP has is that we can talk to the CEO of HCA, we can talk to ascension and say please look at how you're building where you're growing too quickly because it's having negative consequences. And so they're looking at the future of not opening as many programs and maybe even converting some of their GME spots to other specialties where there is a need psychiatry, primary care. And we're really speaking up for the emergency physician to protect our unique role that we believe in collaborative practice. We work very commonly with pas and nurse practitioners, and we believe in collaborative models, but we believe in physician led care, and that every patient deserves to have their care led and seen by an emergency physician, when so part of that was joining ama scope of practice partnership, to really look at the difference and training and to be able to articulate to our legislators who are doing well intended legislation, but to allow independent practice undermines essentially the years of residency and fellowship training that we are doing, and saying that we're different, and that can be a good thing. We can work together. But having a nurse practitioner or PA working independently is not the right thing for patients, we want physician led care. And last week for doctors day, we released a number of videos that show the difference in training between an MP and a PA and a doctor. And I think this is important also because many of our PA colleagues are frustrated that they get put in a category with nurse practitioners and their training is very different than a nurse practitioner. So let's be truth in advertising. Who are we? What are we done, and what is our training. And we've been going to state capitals, we had a number of victories this year in South Dakota, in Texas and Louisiana, of defeating legislation that would have allowed independent practice, to say again, we support our PA and MP colleagues, we want to work together but we want physician led care. pillar number four is looking at rural areas. So this has always been a problem throughout time as we have jobs. They're just not necessarily where people have wanted to go. The West on the East Coast may be a little oversaturated. But there's a whole third of the country where there's not enough emergency physicians. So how do we incentivize people to go there? We don't have a job problem. We have a distribution problem. So many of you signed up for scholarships of HPSP to forgive your loans or went through through uses. What if we had a different system for us medical students where they could have loan repayment if they agreed to work in Kansas for four years after they graduated? How do we incentivize those jobs that would forgive some of their medical debt? And how do we train our residents to have those rural rotations so they feel comfortable working in those environments. And pillar number five is the one I'm most excited about. And this is about expanding the demand and really redefining who we are as a specialty. So interestingly, we're not the first ones to go through this. Anesthesia had a huge surplus in the 80s where everyone was wanting to go into anesthesia. And what happened at that time is they had managed care. And they said back then boy with managed care, we're not going to have as many elective surgeries, we don't need to have as many or cases. And what happened, people panic medical students stopped applying to anesthesia. And for a couple years 50% of their applicants were international medical students, because the demand from us medical students kind of plummeted, which is what we're concerning that we're facing in emergency medicine. So how did they change that? Well, they redefine what they did. They said we have to now do more than just airway right, we have to expand and to pain management, we have to get outside of the or they began opening ambulatory surgical centers expanding their practice. Today, 50% of an anesthesiologist job is outside of the or, and so they really defined who they became. And emergency medicine is at this unique point where we can define who we are, maybe it's telemedicine, maybe it's urgent cares, maybe it is home health, and after people are discharged, maybe it's freestanding emergency departments and taking us outside of those four walls of a hospital and using our skill sets and other places. This is a very care. They oversee 150 critical access hospitals where you work from home. I know Dr. Austin has done this where she can order labs and see a patient through telemedicine and disbelieve them. This is down the street from me in San Antonio of a neighborhood hospital. Right. It's sort of an emergency department on steroids where they have an an MRI, ultrasound CT scan, that really what we become as rapid diagnostic centers, many of the things we used to admit TAS P E's. Maybe some of those can actually be observed and go home. And that can be a growing role of what emergency medicine can be. And many people are expanding beyond their roles traditionally of working in the emergency department and getting into other aspects. Dr. Kellerman, who was a dean at USUS is now one of the first emergency medicines who is a CMO of a major hospital and health system. We have a bunch of people who are in the White House, Dr. Rodriguez has been on the COVID-19 response task force. So I do think there's a lot of light at the tunnel, there's so many good things coming for our specialty, that what I want everyone to take home from this is take a deep breath, it's going to be okay, the world is not falling. And I've really come to the conclusion that life is all about attitude. And if you look at social media, it is exhausting. And it drains our energy because people are always thinking, the world is ending the specialty is over. That is completely untrue. We are in a really good place. And I believe it is. And I keep going back to my TED lasso, because it's all about belief is about believing in a bigger purpose and kindness and knowing that it's going to be fine and seeing the longer vision of where we are as a specialty. And how do I know this? And why am I so optimistic. So this past year, we spent a ridiculous amount of time doing strategic planning. And we were asked to take a.we had a red dot and a blue dot. And the board was asked to put on one end we said specialty of what should ASAP advocate for and then the other end physician. And know that when ASAP started, as we talked about it was because the specialty didn't exist. And so ASAPs purpose was to defend and create a specialty. And much of what we were doing was focused on specialty. And so we all put red dots kind of between that line of physician and specialty, where do we think we are today. And you can see those red dots on the top. But we were somewhere in the middle, but leaning a little bit more toward the specialty. And we talked about the blue dot, where do we need to go? What does the future look like? And you can see that's a pretty notable change. And I will say even in the five years that I've been on the board, it was very difficult to pivot away from specialty care. But I make the analogy that yes, our primary mission is about patients. Yes, the primary thing is about specialty, but you have to put on your own oxygen mask, right when you're on an airplane before you put on your child's mask, we have to take care of ourselves. Because ultimately we represent emergency physicians and if we are not advocating for them and having their back, we're going to lose people this needs to be our focus. And this was a really aha moment I think of a strategic pivot, and what our mission is going to be to some of the things I'm most proud of. Over the summer last year, we created a term of what is an emergency medicine residency, and that many people are using this term in their training, but it is not equivalent to physician training. So asepsis position is that the term resident and residency training should apply only to postgraduate training of physicians that we have other programs for pas for nurse practitioners and pharmacists. But that words matter, we need to start really differentiating ourselves from many of our colleagues of what our training is. We've really tried to hone down on what is the right form of supervision. And this has been a huge challenge. But one of the things that I'm sort of most proud of is is let's start looking at this what is the right amount of supervision? So we had a taskforce last year that was made up of samba for the PAs and the nurse practitioners and every em organization and we've got everyone in a room and said can we agree on what definitions are and what is the right level of supervision? And the group came up with these definitions. That direct supervision is What I do with my residence, right, they tell me about every patient, I have to see every patient and I have to document every patient, indirect supervision as if someone discusses the care with me. But I don't necessarily see the patient, but I hear about them. We talk about the management in real time before the patient is discharged. And that could either be on site, if you're physically in the IDI, or potentially off site, if you're doing it through telemedicine. And there was this category of sort of oversights, where a PA or NP could decide which patients to present that the emergency physician is available for consultation, but only as needed. And they would not necessarily know about the patient in real time. But they would review the chart after the patient was discharged. And ASAP really has grappled with this of what do we recommend and what is our policy. And so last month, we reviewed this and we determined that we don't believe oversight is supervision. It is quality review. If you're looking at a chart after the fact that that doesn't constitute supervision. And if we're really trying to say we want the highest level of care, we do feel that at least in a minimum, indirect supervision is appropriate where you're hearing about the patient, even if it's just hey, I've got a lack in room five, I'm going to sew it up and send them home with after a tetanus shot. But I have to know about that patient before they're discharged. And we talked about off site really only being appropriate for rural emergency departments or critical access hospitals where you couldn't get an emergency physician. But that offsite supervision was not appropriate for urban, suburban or academic hospitals. We launched a campaign on the value of emergency physician of really what is that difference in training, and to really help with our scope of practice battles that are at a state level, and arguing that we agree on physician led care of team based care that everyone plays a very important role in emergency medicine, but that an emergency physician needs to be involved with every care of patients in the emergency department. Another big concern people are having is the degree of consolidation in medicine. We talked about this a little bit at dinner last night. But how many people remember Blockbuster video? Remember, we used to have a card and you have done Friday nights and rent videos a little like be kind please rewind. So what what happened? What happened to Blockbuster Video? Apparently, there's one Blockbuster video that's still open. Where's the blockbuster that's open now? Oregon. Interesting. Okay. Well, in Texas, I'm not even kidding. They're all now freestanding emergency departments. And what I used to work on was a former blockbuster. So what happened to Blockbuster, right, the world evolved around it, we went to Netflix, we went to streaming we went to Apple TV, that there was not a need for renting videos anymore. The way things are evolving in a capitalistic society like the United States is that things are growing because that scale works, right? You have Home Depot has replaced the mom and pop hardware stores. Amazon has put Babies R Us out of business. Things are changing, things are consolidating, because from a business perspective that what was needed to be realistic to be relevant to be able to stay in business. And again, a 70% of your patients don't pay the cost of care. How do you keep your doors open? The only way to do that is to scale both horizontally and vertically. So what does that mean? So horizontal integration is if I have one small group that buys out another small group, or I have one hospital that buys another hospital. And now in the health system. Vertical integration is when you have a employer who is not just emergency medicine anymore, but they buy radiology, they buy anesthesia, they buy the hospitalist because they can scale those costs, right? Instead of having five different medical directors and benefit managers, you have one. So there is some benefit to that. And that is the model that has really succeeded, if you will, in the marketplace. And those are market forces that are driving that. Anyone know how many small groups are left in emergency medicine that have over 60,000 patients? It's about 150. They're left in the whole country. And so we're seeing this increase consolidation is not just for big groups, it's hospitals and health systems and academia that are invested sometimes with private equity, sometimes with venture capitalism, but getting that funding to keep that business model sustainable. So they don't become blockbuster. But what does that impact of consolidation? How does that have an effect on our practice? People are concerned that as things have become more and more consolidated, that we have sort of less control of our practices of what is the impact on our salaries. So I will tell you, the group that I used to moonlight for and do odd with got bought out by a big group. And I asked them what has changed. They actually all make the same amount of money actually, many of them make more than they used to. They are staffing has not changed, but they don't make those decisions anymore about what is the staffing in the emergency department. How many patients an hour Am I seeing? And people feel frustrated by that lack of control. And we're seeing that not only in corporate groups, but even in academic groups in other health and hospital systems in the community. As things have gotten bigger, we have less and less control over those individual decisions. So the FTC the Fed When Trade Commission has come out and said, We are concerned that this is happening across all spectrums of too much consolidation, not just in healthcare, but in Google and Amazon and Disney, right? All of these things are bigger is better. But is it? We want to know what the impact is on consolidation, tell us your stories. And so ASAP met with them. And they asked us to put together a letter. And so we have until April 15. So if you're in a group that has been consolidated, we want to know, how has it impacted your salary? How has it impacted your autonomy? How has it impacted your ability to care for patients, and we're compiling those results of the FTC can make stronger guidelines to look at vertical and horizontal mergers. And just this yesterday, we passed a new statement on private equity and corporate investment in emergency medicine. That says we are increasingly concerned about the expanding presence of private equity and corporate investment in healthcare, that we are concerned that this is impacting our ability to have autonomy in our practice, and that this needs increased scrutiny, and how we really report care and how we take care of patients and better understanding the impact of cost of quality and a physician autonomy. And we're really calling for more transparency, because that's what it comes down to is not just who is your employer, they quote good or bad, but what are their behaviors? Not all private equity groups are bad. Not all academic groups are good. We tend to put people in these buckets. But really, we should ask, what is your contract look like? Do you have due process if you were to get fired? Because you spoke up about not having PPE or there was a patient? Who is risk? Are you allowed to do that? Are you going to get fired for putting your neck out? Do you see what's billed and collected under your name, or you have a non compete clause where if I lose my job, I can't work in a certain area. All of those things are are harmful to physicians. And we have always advocated for the highest ability practice and those good behaviors. And so one way we've changed this year was to create this checklist. So that anyone that exhibits or sponsors or works with ASAP is asked to fill this out. So you can scan them with a QR code when you walk around the exhibit hall. And you can see exactly what they offer and what they don't. With the idea being that if you have increased transparency, you can decide what's best for you. Right? Some people in this group, they don't care about billing transparency, they could care less what's built in their name, but they want a good maternity policy. Right? Somebody else really feels strongly about due process, but could care less about CME reimbursement. So I can't tell you what is good and what is bad. I can only tell you what they offer. And you should decide what job works for you. We've had a number of huge legislative wins this year. So in Georgia, we had a lawsuit against BlueCross BlueShield. They have a list of diagnoses, that if you put on your chart, they would say we're not going to pay you for that, because that didn't really need to be there. So chest pain guy comes in with chest pain, shortness of breath, you work them up, right? Everything's normal, their heart scores low, they go home, your diagnosis is noncardiac chest pain. Well, the insurance company was coming back and saying, Well, Gillian, that's on my list of 800 things that are not an emergency. So that patient didn't need to be there. I'm not going to pay for it. And we said, well, that's kind of BS, right? Because we don't know when the patient comes in. If they have noncardiac, chest pain or something else, we should be looking at their presentation, not on their final diagnosis. But yet that was the plan that BlueCross BlueShield. They had a list of 800 things which included chest pain, asthma, DKA, vaginal bleeding, it went on and on of all things, they didn't consider emergencies. So we said, that's fine. We're going to sue you. How do you like that. And we want and that was a big deal of how we apply this now that retrospectively, they can't use this list of things to say that they're not going to pay for something. In Virginia, they had the same battle this year, with Medicare not reimbursing for services, if it meant a secret list of about 500 different diagnoses. And our position has always been you can't use a final diagnosis to determine what is an emergency. And what is not a national level, we had a huge win this year. So out of network, which I won't go into the details of but effectively this put another 50 to $100,000 in every emergency medicine physicians pocket in the civilian side, because it had this law gone into act, it would have allowed the insurers to decide what to pay you. So essentially, if you are in the community, you're doing od E and you see a patient and you say it's a chest pain, I'm going to charge $100 Right, the insurance company was coming back and saying, We'll give you $5 And you're like $5 I can't keep my lights on. I can't pay for my nurses. I can't get my CT scanner. That's ridiculous. And the insurance company says Take it or leave it. Here's five bucks if you want to be out of network that's on you. But our in network rate is $5. So you say okay, well, that kind of stinks. I guess I'll be out of network because I can't keep my lights on for $5. Well, what happens if you're out of network? There is no process to adjudicate what is a fair price when he baseball players in the audience. I'm not a baseball player, but I learned a lot about the MLB. So when they negotiate their contracts, they come out and say I think I'm worth $10 million and the The baseball league says no, you're worth a million. The arbitrator doesn't average them, they have to pick one or the other of what they think they're worth. And so incentivizes both people to come to a reasonable offer. So what we advocated for is, well, let's do a baseball style arbitration. So if I come and I say, I think the price is $100, and the insurance company says it's five, the arbitrator would have to pick one or the other, not average, the two. And if the insurance comes back with something that's so ridiculous, they're gonna pay us what we're asking for. And that was the law that got passed is we're gonna have this arbitration process, which was a huge win for emergency medicine. But when it got implemented into actually how it was going to be carried out, the devil is always in the details. The government said, we're gonna leave it up to the insurers to decide what a fair rate is, well, what are the insurance companies going to do? Right, they're always going to do something that saves the money. So we sued the federal government, which is an awkward position when you work for the federal government. But it was a step not me. And again, that's the value of Asa because it gives you coverage, right? So you can advocate for us as physicians, and much of what that talk was yesterday, it helps give us a voice that we can make changes. So we sued, and we sued across the country. And we did it with the anesthesiologist and the radiologists. It was a well coordinated effort across the country in multiple different states with the same premise that we are suing because this is an unfair process. And recently, we won in Texas and so the government is now backing off and having to come back with what is their new rule of how they're going to pay for health care. And most excited as we pass the Lorna Breen act, for many people who don't know Lorna Breen, she was an emergency physician who took her own life in the middle of the COVID pandemic. And she had no history of mental illness. She was by all accounts healthy, happy medical director, and tragically took her own life. And this is a topic we need to really start giving more attention to. We have stigmatize mental health, we have made it not okay for people to ask for help. And we are seeing record number of physician suicides, resident suicides, that we need to start advocating for more resources for destigmatizing being able to ask for help when we're not okay. And we got this passed into law just a couple of weeks ago. So yes, we have a number of short term challenges. Bring it on. That is what we do. We're not afraid of challenges. We've had challenges our entire lifespan as a specialty, we were told by people that we were the enemy that we would never exist. And every time we got punched in the face, we got right back up, because this is who we are. And this is what we do. So are there going to be some short term challenges? Yeah, I'm not afraid of that. We've always had short term challenges workforce scope of practice all these legislation out of network billing, we go back to the core of of who we are and why we got in this to begin with. And that was to help patients. It was to be there when nobody else is there at two o'clock in the morning, to be the best physicians we can possibly be to provide our care for patients. And about being the most resilient specialty there is, there are going to be times we get kicked down. That's okay, we can get right back up and learning to really bend with the wind and not break in the storm. And so I see a very bright future for emergency medicine. I'm very encouraged by all the things we just talked about of ways that ACF is strategically pivoting to address each and every one of those issues. And to look forward. There are going to be some short term volatility for sure there is but long term goals and where we're going as a specialty is we're heading in the right direction and I see a very bright future for our specialty and I couldn't be more proud to serve as president of both this chapter and national ASAP and I thank you very very much for your time.