Results
According to the electronic deployment report, the link to the survey was received by 1035 members of the AMA list. Of these, 480 accessed the survey link with 451 answering the eligibility question. Twenty-three were ineligible as they did not work 8 h of clinical time as an EM attending, leaving a pool of 428 respondents who entered the survey proper. Of these, 389 (91% of those entering, 37.6% of those receiving) answered the main survey questions. The number who responded to each individual question is listed in Table 2. The total number of messages sent by the AMA was 17,280 and the response rate to this survey was higher than similar surveys according to the AMA personnel (Kathleen Trout, personal communication February 2, 2012).
The demographic data are displayed in Table 1. The majority of the sample (86%) was certified or eligible for certification by the American Board of Emergency Medicine or the American Osteopathic Board of Emergency Medicine, and over half had been in practice for 16 or more years. Two-thirds worked in a community setting and most were in an ED with a moderate (20–50 K) to high (>50 K) annual patient volume. Over two-thirds worked in a not-for-profit hospital, whereas 21% were at a for-profit site. The most common ED group type was independent group practice (41.3%), followed by hospital employee (27.2%) and contract management group (20.6%).
Over half of the respondents indicated that they did not have a right to full due process (defined as a right to a review before the members of the medical staff) or that the hospital administration could order their removal from the clinical schedule (Table 2). Many (18.5%) were unsure of their status in this regard. Looking just at those who knew the answer to the question, 62% (197 of 317) reported that their employer could terminate them without full due process and 76% (216 of 284) reported that the hospital administration could order their removal from the clinical schedule. Nearly 20% reported a possible or real threat to their employment if they raised quality-of-care concerns.
Financial pressures included 12.3% reporting minor or major pressure to admit patients they believed could be treated as outpatients, and 17% reporting pressure to order more laboratory or radiographic testing on patients than was clinically necessary. One-third reported pressure to discharge home Medicare patients who may not qualify for payment if admitted, and 15.2% were pressured to discharge or transfer uninsured or Medical Assistance patients.
Regarding their career experiences, 70 (18%) had been terminated or removed from the schedule without a fair hearing, 25 (6.5%) had been threatened with termination when raising quality-of-care issues, and 27 (7%) threatened with termination when raising financial questions. Written comments were also received from the respondents and they are available as an Appendix (see Appendix in the online version of this article).
Given the for-profit nature of EM CMGs, we compared the responses for physicians in this arrangement to those reporting a position as a hospital employee or in an independent group practice (Table 3). We found statistically significant differences in the number that could be terminated without due process or removed from the schedule by a hospital administrator. Most remarkably, 90% of these physicians could lose their privileges without a fair hearing, and 92% could be terminated by a hospital administrator. Additionally, more physicians working for a CMG reported a real or possible threat to their position if they raised quality-of-care concerns. A higher percentage of CMG physicians reported pressure to admit patients who they believed could be discharged (18% vs. 12%) and to discharge or transfer uninsured or Medical Assistance patients (22% vs. 13%), but these differences were not statistically significant.