Paying the Price

The September, 2006 issue of Emergency Medicine News published a letter I wrote regarding emergency department overcrowding in Peoria and the consequences of what happens when doctors bring up sensitive topics. ("Paying the Price for Speaking Up").

Emergency Medicine News:
September 2006 - Volume 28 - Issue 9 - p 10-11



Paying the Price for Speaking Up

Carroll, John A. MD
Peoria, IL

Editor:

I agree with Dr. Edwin Leap's opinion in his March column, What Are We Afraid Of? (2006;28[3]:15.) Physicians need to go public with patient care concerns. I believe physicians don't speak up because they fear losing their jobs and being marginalized in their community. That was my experience.

I live in a mid-sized, Midwestern city, and in September 2001, I was placed on six months' probation from my job as an emergency physician at a large medical center. I was confined to working in the urgent care center. My probation occurred the day after I wrote a letter to the hospital administrator (with copies to all the attending physicians in the ED including the director) about my concerns regarding long waits in the ED. When I wrote the letter, the ED was crowded, patients were lying on gurneys in ED hallways, and patients were signing out because I could not admit them to a bed in a timely fashion.

After I started my probationary period, the ED director told me that I could return to the main ED if I were evaluated by the hospital's wellness committee for burnout (a point not mentioned in the probationary letter). The hospital administrator referred to me as a cancer in the department who needed to be cut out before it metastasizes.

The ED had a dismal patient satisfaction rating of 33 percent and a low employee satisfaction level at that point. As the weeks went by, I continued to work in urgent care, but I refused to be evaluated by the wellness committee. The administrator who had referred to me as a cancer was discussing my case inside and outside the hospital. I was made the problem rather than placing the blame on the systematic deficiencies that plagued the ED.

While working an urgent care shift in December 2001, I was called to the administrator's office, and with another administrator, the ED director, and hospital legal counsel present, I was fired. After 20 good years as a resident and staff physician there, I packed up my gear and left.

The reason I wrote to the hospital administrator that September was that ED crowding and hospital bed capacity are systemic hospital issues. I also did not think the ED director would do much. Besides being the ED director, he had been the project medical director for the previous eight years, and he was still on the payroll of the city's only private ambulance company, the exclusive provider of the city's paramedic and transport prehospital care. The hospital is the base station for the area, and is the main supporter of the lucrative private ambulance service. Our fire department is held to a nontransport basic level, and according to the firefighters, obstacles were thrown up over the years by my boss when they attempted to advance their level of care for the citizens of the city. This arrangement was known all over the state in EMS circles and considered a serious conflict of interest by many.

Before and after I was fired, I attempted to go through channels within the medical center to explain my concerns for the prehospital patient and about the long waits in the ED. Administrators, corporate, and the ethics committee would not address my complaints. Letters to the JCAHO and the state department of public health were not helpful.

I have picketed the hospital, written letters to the local newspaper, and presented frequently to the citizens' forum at city council meetings. I also have written a web log, www.peoriasmedicalmafia.com about the past five years. Recently, a local newspaper editorial stated that our ED was seeing almost twice the number of patients that the original ED was designed to accommodate safely, and it noted that diversion of patients due to insufficient hospital bed capacity was a significant issue.

The most difficult part of this experience isn't being unemployed. It is abandonment by people who I thought would stand up for quality care issues facing our community. Many of my physician mentors who taught me patient care when I did my residency there no longer will see me or speak to me. The religious community that founded the medical center is silent, and the business community in our close-knit city supports the medical center and the private ambulance company. The EMS issues here that could be improved for public health reasons are relegated to secondary importance, with money taking precedence.

I would do this again but only reluctantly. Going public is necessary for physicians if we want positive change. It is not a heroic thing to do. It should be expected. But be ready to pay the price.

John A. Carroll, MD
Peoria, IL

© 2006 Lippincott Williams Wilkins

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My comments in 2021--

1. Being a whistleblower is not all that is cracked up to be.

2. And when one is a whistleblower in their home town and then does not leave their home town, be ready for some sadness.

3. And when one is a whistleblower in their own home town and then pickets the number one industry in their own home town, see how that works for you. 

4. The elevator door is the best way I can explain the phenomenon. People will talk when the elevator door is closed. But when it opens, all talk stops and everything stops. 

5. I posted this on April 18, 2014--Please read this article from Medscape.

6.  July 9, 2014--Read this article too about whistleblowers at the VA. Here are a few paragraphs about what a VA Emergency Medicine physician in Phoenix thought about her VA facility and what happened to her when she spoke up:

The head of the medical inspector’s office retired June 30 following a report by the Office of Special Counsel saying that his office played down whistleblower complaints pointing to “a troubling pattern of deficient patient care” at VA facilities.

“Intimidation or retaliation — not just against whistleblowers, but against any employee who raises a hand to identify a problem, make a suggestion or report what may be a violation in law, policy or our core values — is absolutely unacceptable,” Gibson said in a statement. “I will not tolerate it in our organization.”

A doctor at the Phoenix veterans hospital, where dozens of veterans died while on waiting lists for appointments, said she was harassed and humiliated after complaining about problems at the hospital.

Dr. Katherine Mitchell said the hospital’s emergency room was severely understaffed and could not keep up with “the dangerous flood of patients” there. Mitchell, a former co-director of the Phoenix VA hospital’s ER, told the House committee that strokes, heart attacks, internal head bleeding and other serious medical problems were missed by staffers “overwhelmed by the glut of patients.”

Her complaints about staffing problems were ignored, Mitchell said, and she was transferred, suspended and reprimanded.

Mitchell, a 16-year veteran at the Phoenix VA, now directs a program for Iraq and Afghanistan veterans at the hospital. She said problems she pointed out to supervisors put patients’ lives at risk.

“It is a bitter irony that our VA cannot guarantee high-quality health care in the middle of cosmopolitan Phoenix” to veterans who survived wars in Iraq, Afghanistan, Vietnam and Korea, she said.

Scott Davis, a program specialist at the VA’s Health Eligibility Center in Atlanta, said he was placed on involuntary leave after reporting that officials were “wasting millions of dollars” on a direct mail marketing campaign to promote the health care overhaul signed by President Barack Obama. Davis also reported the possible purging and deletion of at least 10,000 veterans’ health records at the Atlanta center. More records and documents could be deleted or manipulated to mask a major backlog and mismanagement, Davis said. Those records would be hard to identify because of computer-system integrity issues, he said.

Rep. Jeff Miller, R-Fla., chairman of the House veterans panel, praised Mitchell and other whistleblowers for coming forward, despite threats of retaliation that included involuntary transfers and suspensions.

“Unlike their supervisors, these whistleblowers have put the interests of veterans before their own,” Miller said. “They understand that metrics and measurements mean nothing without personal responsibility.”

Rather than push whistleblowers out, “it is time that VA embraces their integrity and recommits itself to accomplishing the promise of providing high-quality health care to veterans,” Miller said.

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Viewpoint

Give Me Due Process, Not Water Bottles

Lin, Ming MD

Emergency Medicine News: October 2021 - Volume 43 - Issue 10 - p 5

doi: 10.1097/01.EEM.0000795752.57492.d2

Figure: 

contract management, ACEP

I first learned about the American College of Emergency Physicians as an emergency medicine resident almost 30 years ago. The organization was and still is extremely valuable in establishing emergency medicine as a specialty, providing policies and guidelines to improve and standardize how it is practiced. I also enjoyed attending ACEP's conferences where I reunited with colleagues and shared ideas with like-minded individuals while absorbing useful and new educational materials.

There were always signs, however, that the tentacles of corporate medicine lurked behind ACEP's façade of professionalism and academia. Contract management groups (CMGs) backed by private equity always had the largest booths and banners in the exhibit halls of ACEP's scientific assemblies. Like Hansel and Gretel, it was not difficult to be seduced by their water bottles, free parties, and potential six-figure salaries.

Corporate medicine, the practice of medicine by nonmedical personnel, is illegal in most states, but many CMGs skirt the law by setting up local companies to make it appear as if a group is physician-owned. One does not need to look far to see that medicine's desire to help the less fortunate and a corporation's desire to maximize profit create a disastrous combination. Early in my medical career, pharmaceutical companies gave physicians studies that narcotics were not as dangerous or as addictive as common sense and medical science led us to believe. Like Pavlov's dog, I digested this information (along with the free lunches) and incorporated this new dogma into my practice, not realizing that the studies were not only biased and flawed, but were intended to favor profit over patient safety. Today, drug company representatives are banned from many hospitals and emergency departments.

Emergency departments that utilize CMGs also produce spineless ED directors who lack the incentive to advocate for the safety of patients or staff. After 9/11, at the busiest and closest trauma center to the World Trade Center, my ED director was able to clear our ED and cancel all elective procedures within an hour. He did not need the blessing of administration to make the best decisions for his patients and staff. This is in stark contrast to today's ED directors who are hired by CMGs. Their primary objective appears to be to preserve the lucrative contract at all costs.

Recently, while scrolling through one of my social media pages, I came across a statement that ACEP posted on its website when I was terminated by my CMG employer for speaking out about the safety of my staff and patients at the beginning of this pandemic. (Dr. Lin is suing PeaceHealth, which operates PeaceHealth St. Joseph Medical Center in Bellingham, WA, and TeamHealth, the contract management group under which he was contracted to work, for wrongful termination. Read about his dismissal in EMN. 2020;42[5]:1; https://bit.ly/3f8RXfX.)

“ACEP is aware of the termination of the emergency physician in Washington.... We have reached out and have offered to connect him with resources to discuss steps that could be taken. Physicians should not and cannot be punished when advocating for workplace safety in such a high-risk environment.”

My inability to find this page today has further fueled my concerns that ACEP may not be a true advocate for the emergency physician's due process, something the college has stated numerous times.

I have been offered support by hundreds of people, reporters, the American Academy of Emergency Medicine, the Washington State Nurses Association, the American Civil Liberties Union (which is backing my wrongful termination suit), local EMS organizations, unions, politicians, worker advocacy groups, and even the local Native American nation. Buried among them was a message from an ACEP board member offering his support.

But unlike other groups who have supported me, ACEP's ties with the corporate world are more obvious. Was the college utilizing my unfortunate situation to falsely portray a virtuous image or is it truly interested in doing what is necessary to ensure due process for all emergency physicians? My apprehension only grew not only as I discovered that my state ACEP chapter did not support an internally driven resolution to provide due process but also that its president is an employee of the CMG against which I have brought a wrongful termination suit.

ACEP has an opportunity to be a true advocate for the bedside emergency physician and demonstrate that it offers more than mere talk. I ask my fellow physicians to join me at this year's ACEP Scientific Assembly to call for ACEP to pass Dr. Robert McNamara's resolutions 29 and 44 in full. (See article by Mitchell Li, MD, and Meghan Galer, MD, about these resolutions on p. 3.)

These will prohibit ACEP members from denying due process to its members and will mandate transparency in billing for the hard work of all emergency physicians. This is a great opportunity for ACEP to demonstrate that it is not betrothed to corporate medicine or some private equity company as many of us who sacrifice ourselves on the front line believe that it is.