cardiac arrests, the child died, but there were no resources left totreat the mother stricken with the same disease. She died soonafter, while her remaining children stood outside the tent.

“Now you have a dead mother, a dead child and 2 orphanswho ain’t going to make it in that culture,” Burkle said. “Thereare a lot of very difficult decisions you need to make. Thedecision to doing anything is based on a lot of things, not justmedicine.”

Emergency physicians must prepare for cultural clashes aswell. Burkle recalled several instances of being unable to treatpatients because of obdurate tribal elders, and Lanier’s attemptsto evacuate a young woman with spinal fractures were thwartedbecause the family could not spare a chaperone.

At a minimum, emergency physicians wishing to dohumanitarian work in developing nations should attend trainingsessions, such as the one-week course at the Cleveland Clinic orthe 3-week Health Emergencies in Large Populations courseoffered at Johns Hopkins.

PRACTICING WITH THE BARE NECESSITIESPhysicians abroad work in a range of conditions, and

veterans stressed the need for flexibility and strong physicalexam skills. Some locations may have no electricity or evenrunning water, and equipment will be limited to intravenouscatheters, fluids and antibiotics.

“You’ve got your eyes, your hands, your ears,” Burkle said.“Do you have the expertise to practice the science and the art ofmedicine without all the bells and whistles that you are used to?That’s the shock.”

Others, like a Kenya hospital where Dr. Scott Sasser worked,may have reasonable facilities and serve 100,000 patients a year.

But such conditions may be no easier. Sasser, an assistantprofessor in the Department of Emergency Medicine at theEmory University School of Medicine who has worked in andout of Africa for the last decade, says his Kenya post wore himdown. Just half a dozen physicians handled the patient load.Sasser assumed responsibility for not only the emergencydepartment, but about 70 patients in the pediatric ward. And helived at the hospital.

“It was a 24-hour-a-day job,” he said of the Kenyaassignment, where he was sponsored by World Medical

Mission, the medical arm of the faith-based organizationSamaritan’s Purse.

But at the same time, as an American physician, Sasser saidhe never felt more free. A lot of the headaches of a US practice,liability, insurance and paperwork, simply didn’t exist. Insteadof high-tech diagnostics, the doctor-patient relationship wasstrictly hands on.

“There’s a certain freedom that’s wonderful,” he said.“You’re only taking notes to help you take care of the patientthe next day. It takes you back to the roots of what it’s likebeing a doctor. You perform the exam, there’s no expensive test.So you get more human contact, you rely more on your senses;it feels like what you’ve been trained to do as a clinician.”

MAKING A DIFFERENCEDoctors seeking just 2- or 3-week rotations in foreign

countries should generally seek smaller, faith-based efforts, butit can still take months or more than a year to prepare. BenBusch, an emergency medicine resident at Doctors Hospital inColumbus, Ohio, collected medicines and supplies fromhundreds of doctor’s offices in Columbus for victims of theAsian tsunami. But he didn’t reach Sri Lanka until March lastyear. After contacting several organizations, he finally found thefaith-based group MercyWorks which helped sponsor the trip.

Busch, involved in international relief efforts since hismedical school days at Michigan State University, shares theview that growing numbers of doctors are interested in travelingabroad to offer care in developing nations. The interestespecially exists, he said, among younger doctors.

More medical schools are offering their studentsinternational opportunities simply because the young doctors-in-training are demanding it, he said.

“I think people have a better cultural awareness because theworld is so small these days,” he said. “The desire probablycomes from the fact that today’s young doctors have grown upin a more global culture. We see all this terrible stuff going onaround the globe, and we want to make a difference.”

Eric Berger is a science writer at the Houston Chronicle. Hecan be reached at.sci.writer@gmail.com

doi:10.1016/j.annemergmed.2006.02.016

A CLASH OF PRACTICE MODELS: DEBATE ROILS AROUND MEGA-GROUP MEDICINEGeorge Flynn

Special Contributor to Annals News and Perspective

In government, the political arguments rage on about whatextent of local control is best for a democracy. Business sectorsdebate the same issues, whether a large corporation or locallyowned businesses is better suited for consumers, employees andthe community in general.

Increasingly, the delivery of emergency medicine triggersthose same fundamental disputes. With a basic trend towardconsolidation of emergency physician contract providers overthe past several years, the dialogue also is escalating about theimpacts on physicians and the patients served by them.

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“Whether you are talking about education or anything else,this is a political and philosophical argument,” says Dr. RobertKnopp, founder of the Regions Medical Center EmergencyMedicine Residency in St. Paul, Minnesota. “Should there be alarge corporation involving large geographical areas managingsomething? That goes, for that matter, for Wal-Mart and theUS government versus locally controlled providers of goods andservices.”

Many emergency physicians decline to give pat answers onthe issue, explaining that a contract provider’s size alone doesn’tin itself answer the deeper questions about the quality of workenvironment and compensation.

“There are going to be some things that are going to bebetter because you are in a bigger group, and some things thatare not going to be better because you are sort of faceless in abig group. You don’t have much of a say in that one,” says Dr.Timothy Seay, a leader in a Houston area contract group. Seaysays he bluntly advises new emergency physicians that there isn’ta one-size-fits-all approach. While many groups featurecooperative-style ownership portions for each physician andshared authority, he notes that such arrangements require moreeffort and involvement on the part of individual doctors.

“There are a lot of doctors who have no interest in being in a‘democratic group,’” he says. “They want to go to work and gohome, and they aren’t interested in the extra work involved inbeing in that kind of group. They need to sort of look withinand see if they have that desire.”

In contrast to the democratic model, the arrival of stockmarket-driven, big business into emergency medicine hassounded sharp alarms for many physicians. The AmericanAcademy of Emergency Medicine (AAEM) has been a constantcritic of mega-groups, saying they pose huge threats to theexisting prohibitions against the corporate practice of medicine.

“The concern we have is that the physician is supposed to bethe advocate for the patient,” says Dr. Robert M. McNamara, apast AAEM president and chief of emergency medicine atTemple University Hospital in Philadelphia. “Emergencydepartments are frequently saddled with patients–the uninsured,unwanted patients–that are not profitable to the emergencypractice or the hospital system. When you are in a business, whywould you cater to those patients? It creates a potential for aconflict of interest.”

EMCARE AQUISITIONS ON THE RISEWhile the arguments flare, available statistics indicate that

acquisitions of emergency contracts continue on the upswing.Modern Healthcare reported in 2003 that the nation’s largestprovider, EmCare, had an 8% increase in clients from 2001 to2002. It went from 250 to 270 clients in that period. In itscurrent promotional materials, EmCare boasts more than 300client hospitals in 37 states, with more than 4,500 physiciansunder contract.

In October of 2005, EmCare’s parent company, EmergencyMedical Services L.P., provided more data in a filing with theUS Securities Exchange Commission for an initial public

offering of shares designed to generate $125 million. Thecorporation reported that emergency physician reimbursementsin the nation total about $10 billion annually. About 4,700 UShospitals maintain emergency departments, and about 67% ofthose outsource staffing for that function. EmCare stated that ithas 32% more contracts than its closest competitor, although itcurrently only has a 6% share of the total outsourcing marketfor emergency departments.

“The market for outsourced emergency department staffingand related management services is highly fragmented, withmore than 800 national, regional and local providers,” thecompany said in its filing. In the fiscal 2004 year, EmCarereported about 5.3 million patient visits in 38 states.

MEGAGROUPS RARE IN OTHER SPECIALTIESWhile all medical specialties have physician contract groups,

emergency medicine appears to have attracted more large groupsspanning states or national regions.

“There may be a few exceptions, but generally you do notfind the mega-groups in heart surgery, neurology, pediatrics andso on,” says Knopp, who has 30 years of experience in thespecialty. “As a general measure, emergency medicine isdifferent from most specialties in that there are these largemega-groups.”

Local control dominates other specialties, he says. “Thosephysicians are in a hospital or a group of hospitals in a localarea; they are the ones who develop the policies, work with thehospitals and manage the medical care.”

Emergency medicine is somewhat unique because it evolveddifferently from most specialties, he says. “First of all, it is oneof the youngest specialties. Even though ACEP was founded inthe late ‘60s, most other specialties were established decades oryears and years earlier. Emergency medicine came out kind ofby accident.”

Forty or so years ago, “terrible care would be delivered inemergency rooms, by physicians who had no commitment ortraining in emergency medicine,” he says. Then came thenational calls for reform and improvements. Knopp saysphysicians from other specialties were attracted to emergencywork, and the specialty was born. That disparate group had nospecific rules, and some physicians were more entrepreneurialand business-oriented, Knopp explains.

“They did work in one hospital and saw that they were doingwhat they felt was good work. They thought, ‘I’m able toconduct this business, and maybe I should try it again in adifferent hospital.’”

Knopp says many hospitals were in need of the help, “so itwas easy for the emergency physicians to move on, and theycould hire moonlighters” – residents who would work cheaplyand at night in an emergency department. The contract-providing physicians, meanwhile, found out “they could makequite a profit off that.”

With the early problems of hospitals in providing emergencycare, administrators welcomed the contract arrangement, Knoppsays. “Hospital administrators said, ‘Oh, this guy is going to

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take this problem off my shoulders so I don’t have to worryabout it as much.’ Some of the group leaders realized that, ‘Gee,this could be a business, and I could do very well. And I couldalso improve care because I would review the charts on how thecare was delivered.’”

While the start-ups were not uniformly successful, those whosatisfied the needs of hospital administrators could expand toother hospitals and gain contracts by their emerging trackrecords, he says.

“Like any endeavor, Wal-Mart or anything else, it startssmall. And if somebody does well, at least by administrators’standards, it would grow.”

Although EmCare has been through a number of owners, itcan boast more than 33 years of experience. Knopp notes thatlarger groups can have advantages, such as economies of scale indelivering emergency services. He believes that “in a perfectworld, the ideal would be to have a group of emergencyphysicians manage locally.” Big groups argue that there is localcontrol because of local or regional medical directors on theirstaffs, but Knopp is concerned that mega-groups may have atendency to hire physicians who are not residency trained orboard certified in emergency medicine, especially in smallermarkets such as rural areas.

CORPORATE PRACTICE OF MEDICINE?Concerns by McNamara and AAEM about mega-groups go

all the way to questions about whether they represent corporatepractice of medicine, which is illegal in 37 states, according tothe American Medical Association. Foremost is the worry thatprofit-driven approaches shortchange individual physicians aswell as patients.

Revenue and earnings increases are fueled mostly by anobsession with growth by mega-groups, McNamara says.“There’s a sharp need for contract companies to grow or takeover more lucrative contracts.” That drive for acquisitionscomes because there are eventually limits on higher profits fromexisting franchises, he says.

“They come in and they work their magic with charts andcoding and billing and collecting, but then they top out,”McNamara says. “Groups that are owned by venture capitalistswant a good return on their money; you’ve got other groupsthat are publicly traded, and those investors want a return ontheir money.”

EmCare had been involved in a bankruptcy when its then-holding company, Laidlaw International, filed for Chapter 11reorganization about 5 years ago, exiting from bankruptcy inmid-2003 with fresh financing of about $1.2 billion. Early lastyear, it sold EmCare and its AMR ambulance company for acombined $828.8 million. The buyer was the OnexCorporation-led investor group, which set up the EMS limitedpartnership holding group for AMR and EmCare.

The company’s promotional material emphasizes itsexperienced leadership, “A” rated malpractice insurance,performance-based physician compensation system and the factthat 95% of its physicians are board certified or board prepared.

However, one problem in dealing with the corporate structurewas reflected in attempting to get comment for this article.

EmCare headquarters in Dallas referred calls to its AMRoffices in Colorado. There, the corporate communicationsdirector advised by telephone message that she would be gonefor a week, and that inquiries should go to her assistant, whodid not return repeated calls for comment. After nearly a monthof requests, the communications director finally responded byemail with a “no comment.”

California Emergency Physicians Medical Group, known asCEP, may represent a more physician-centered approach. It wasfounded in 1975 and now has contracts with 54 emergencydepartments and 19 ambulatory practices. It represents about800 emergency physicians who handle about 19% ofCalifornia’s yearly volume of emergency department traffic.

THE GROUP MODEL ALTERNATIVE“We try to give the best of both worlds – local autonomy but

central support from our partnership,” explains Dr. Wesley A.Curry, CEP’s chief executive officer and a member of the groupsince 1982. Six CEP partners have been presidents of the ACEPCalifornia chapter.

Despite the growth, the group intentionally remains ageneral partnership rather than a professional corporation.Known as a democratic contract provider, every member canvote on CEP affairs and is eligible for the same maximumownership parity as other members.

“We’ve got a model that we think works really well, forthe physicians and the hospitals,” Curry says. “We’ve lookedat the costs of investor companies as well as solo companies.We’ve found our costs are lower than even doctors in solopractice.”

Curry says CEP is believed to be the largest true partnershipof physicians in the US, with the exception of the multi-specialty Kaiser. “I don’t think it is an issue so much of investor-corporate practice of medicine versus non-investor owned. It is amatter of who is the beneficiary – what is the real ownershipand equity of the physician group?”

He says there is no real difference between investor-ownedgroups and so-called physician-owned groups where the realownership remains in the hands of only 2 or 3 physicians whocontrol 20 or 40 or more doctors. “What is unique about CEPis that we’re both very large for a physician group, but we alsohave no outside investors. So we have very broad ownership,such that no physician owns more than 0.5 percent of thecompany.”

Seay says there are “huge disparities” on whether a group canreally be called democratic. Much of it depends on basictransparency of accounting and solid support, he explains. “Ininterviewing, most of the graduates I talk to don’t want to beactive in the management of a group. They at least want toknow where the money is coming and going. It seems to be asimportant as how much money they are making – not quite,though.” He says his group, Greater Houston EmergencyPartners (GHEP), which has about 75 doctors and represents

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12 hospitals, “is a representative democracy, and that seems tomake everybody happy. We’ve got a lot of people activelyinvolved in the group.”

Seay, regional medical director for GHEP, says improvedefficiencies have enabled it to pay physician bonuses of from$10,000 to $50,000 annually. It boasts combined revenues of$38 million and compensation within the top 15% range foremergency physicians.

KEY QUESTIONS FOR EMPLOYERSKnopp says it should be the responsibility of every residency

to prepare emerging physicians on how to best evaluate providergroups, large and small. He gave his key points in assessingthem:● Do physicians working in the group have a say in what is

going on? Is it possible to become involved in the leadership?

● What percentage of the group are residency trained andboard certified in emergency medicine?

● How are the physicians paid? Are there relatively openbooks? Are there reports that indicate where the money goes?Is that well communicated and understood? Are the physi-cians fairly compensated for the work they perform?

● What is the focus on quality of care? Are efforts continuouslymade to improve quality of care, or is it mainly a deliveryservice that is most focused on the business aspects?“One needs to be focused on business aspects because there is

competition for these contracts,” Knopp said. “But the mostimportant thing is to have all the physicians involved in theimportant decisions that are made. If those decisions are made athousand or 1,500 miles away by a small group of leaders,without involving physicians who actually work in theemergency department, then that’s a real problem.”

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