The Downside of CMG Residency Programs
Here I am nearing the end of my term as president, and I experienced a small victory that thrilled me.

A fourth year student emailed me with a question. He had discovered that a contract management group (CMG) ran a residency program where he had interviewed. He wanted to know how I thought this might impact his experience.

I told him that all residency programs must be accredited by the ACGME and must meet extensive requirements designed to ensure that residents receive a quality education. All programs are reviewed on a periodic basis. Further, I said I thought that the core teaching faculty at these programs would be dedicated to teaching and ensuring a quality education.

But there were potential drawbacks, I said. CMGs sponsor residency programs for a reason. Were they really interested in education? That’s a hard claim to make when they actively recruit non-EM trained residency graduates to work in the EDs they control. We have heard that CMGs use training programs as a venue for inculcating young doctors with the idea that CMGs are good employers and treat their people fairly. I will let AAEM members judge the truthfulness of that concept. Little freebies like scrub shirts with the company name embroidered on them go a long way towards winning hearts and minds. But did the student really want to endure 3-4 years of that propaganda?

I let the student know about the horror stories we have heard. CMGs were reported to assign residents to work on shifts alongside weak attending physicians. They counted on the residents to make up for the deficiencies of those attendings. Or they might demand that residents moonlight in hospitals controlled by the CMG. Nothing better for your business model, I suppose, than a ready bullpen of replacements to fill in when you have staffing problems. But is that best for the residents?

And what happens when a resident approaches a faculty member to ask about a job opportunity or the pros and cons of different employment models? Will that faculty member offer unbiased advice? Can they do so when most CMGs offer contracts that allow them to fire their docs without cause?

But having an opportunity to tell a single student that there are pros and cons of choosing a training program sponsored by a CMG is not my little victory. It’s the fact that I was asked the question. Listen:

For years, members of the AAEM boards have been pulling out their collective hair and suffering over the question of why so many emergency docs have been willing to line up to work in EDs controlled by the CMGs. Mass insanity? Masochism? Just plain stupidity? Perhaps. But most board members over the years believe that the primary problem has simply been failure to understand.

Many of our colleagues think they have a good thing going, working for these CMGs. Many think they have no options. Or, they do not understand how they are being fleeced.

The obvious solution has been education. So board members, especially the president, travel to residency programs and meetings, telling the story of why we believe that contract holders (not just the large CMGs) are bad for both patients and doctors. How their business model violates the law and endangers physicians’ licensure. We try to put information about CMGs in our publications, meetings and promotional material. And, frankly, our failure to spread the word more effectively has been frustrating.

But the tide is turning. Over two years, I have spoken at dozens of programs, and the interest expressed by young physicians is palpable. We recently began trying to address student emergency medicine interest groups (EMIGs) during residency visits when possible. I get more and more inquiries about fairness and working conditions from doctors at all levels of training. Take home message: the word is spreading. Not as fast as I had hoped, but it is spreading.