Eat what you kill

Editorials / Commentaries

CJEM 2000;2(4):228

Warning: This editorial contains language that will be offensive to some.

You race from patient to patient, spending the minimum necessary time with each. You work 10-hour stretches without stopping or eating, because patients are waiting. At any given time, 17 decisions hang over your head. When the shift is over, you bolt for the bathroom to empty 923 mL of concentrated urine from your bladder. Then you sit down in front of the stack of blank charts you didn't have time for during the shift, but you're too exhausted to write them up. You envy colleagues in other specialties who stop for lunch and socialize in the doctors' lounge. Your friends ask, "Can you do this for more than 15 years?" You are an emergency physician, and many of your problems are self-inflicted, the result of fee-for-service ("eat what you kill") remuneration.

The best thing about fee-for-service (FFS) is that it motivates us to work like dogs, to see more patients faster and to handle more volume than we otherwise would -- or perhaps should. The worst thing about FFS is that it twists our motivations. FFS rewards high volume and low intensity. At tax time, the physicians who spent the fewest minutes per patient and treated the most stubbed toes will mail the biggest cheques to Ottawa. FFS causes EM groups to limit their size and maximize single coverage to maintain income. This leads to longer patient waits, physician overload (volume stress), job dissatisfaction and burnout. FFS encourages us to avoid complexity and refer early. In an FFS system, the most sought after cases are those that don't need a physician at all: bumps and bruises, suture removals and burn checks. FFS remuneration encourages high-skill workers to perform low-complexity work. Financially motivated EPs* will be less inclined to go the extra distance with sick patients and less likely to develop, apply and maintain the acute care skills that define our specialty and give us credibility with other hospital specialists.

After 13 years in high volume, high acuity FFS emergency medicine, I crossed over to the dark side and joined a group that is paid under an alternate funding agreement. My new group has better physician coverage and suffers less volume stress. I can spend more time with patients in the trauma room. I don't mind treating people without health care coverage, and I don't lose sleep when government billing clerks reject claims for services I provided. I no longer bill or pay a billing service. I don't compete with my colleagues for "wound checks" and I'm not tempted to "throw a stitch" into small lacerations that don't need one. I get a 2-month sabbatical every 2 years. I drink my coffee while it's still warm, and usually have time for lunch. My partners see patients until the end of their shift and don't loaf. Like everyone else I know who's made the switch, I like alternate funding. I believe it will increase my longevity.

FFS is a dinosaur. The Ontario and Nova Scotia governments have already endorsed a formula, based on patient volume and CTAS (Canadian Triage and Acuity Scale) acuity levels, to determine appropriate ED staffing needs. In this issue,¹ Drs. Alan Drummond and Robert Drummond chronicle the Ontario government's efforts to introduce alternative funding agreements (AFAs) in EDs. AFAs are on the way, and clever emergency groups will position themselves for the future.

Reference

1. Drummond AJ, Drummond R. The Alternative Funding Agreement for emergency services in Ontario: a new compensation method for rural emergency departments. CJEM 2000;2(4):232-6.

*A rare entity. Financially motivated physicians seldom enter EM residencies.