The Biggest Challenge Facing Emergency Medicine Might Surprise You: Dr. Ryan Stanton, President-elect of the American College of Emergency Physicians and Medical Director for the AMR/NASCAR Safety Team

Lindsey Smith

Hi, I'm Lindsey Smith, welcoming you to Raise the Line from Elsevier, an ongoing exploration about how to improve health and healthcare.

Today we're heading into the emergency department to explore the major challenges facing providers in that important space with Dr. Ryan Stanton, president-elect of the American College of Emergency Physicians (ACEP). Dr. Stanton is also president of Central Emergency Physicians in Kentucky, which is an independent practice group serving hospitals in the region.

In addition, he is EMS Medical Director for Lexington Fayette Urban County Government and Medical Director for the American Medical Response and NASCAR safety team. And on top of all of that, somehow he finds time to be chief medical contributor for the Fox TV affiliate in Lexington and host of the ACEP Frontline Podcast.

Thank you so much for joining us today, Dr. Stanton.

Ryan Stanton

Thank you. Appreciate it.

Lindsey Smith

So let's start with learning more about your background. In your case, pursuing a career in medicine is perhaps maybe not a surprise because you had a strong role model in your family. Can you tell us more about that?

Ryan Stanton

Yeah, so my father was actually the first in that side of the family to even go to college, and he went on to medical school and became a vascular surgeon. Didn't know exactly what he wanted to do initially, but ended up falling into surgery and then vascular surgery. I was born in Atlanta, Georgia when he was working there and then we moved when I was nine up to East Tennessee, because he was tired of taking two hours each direction to get to and from work, and so we wanted to move to where he was five minutes from his workplace, which is what we found in East Tennessee, at the VA there and East Tennessee State University.

Then growing up in that environment, I actually didn't know what I wanted to do. I was fourteen, I started doing media, I started doing radio narration for a church broadcast, worked for public radio through college, did TV production, and even thought about going out west and trying my hand at that. But, you know, there wasn't a huge market for a six-foot-five Southern guy anywhere, really. So I just found, just in that environment and seeing the schedules and the challenges, and I still loved healthcare, and then felt like that if I wanted to do healthcare, I could find my potential and niche within media through healthcare. And so that's actually what I ended up doing, was when I went to med school, and then initiation of residency, is continued pulling the media back into that.

Lindsey Smith

Thank you for sharing that story with us about your father. And it sounds like you had a strong foundation early on, kind of like a very up close sense of what the work looks and feels like day to day. But you picked emergency medicine. Can you tell us why that was attractive to you?

Ryan Stanton

Well, this is for those that are students and in the process through medical school: I hated the first two years of medical school. Hated. And I still remember, speaking of dad, sitting back there on the porch swing of their house, talking about the fact that I didn't know if this was for me and whether I needed to stay in medicine or try something else. And then third and fourth year, I loved the rotations. But loving the rotations, I didn't love any rotation long term. I found out that I hated rounding and I hated clinic. I loved a little bit of every rotation.

I loved OB, delivering babies and doing that sort of thing, but then you get to the point after a month you're like, I guess somebody's pregnant again. Or you go into orthopedics and you're like, I guess somebody's got a bad hip again, or whatever it may be. Cardiology, I guess this case is going to involve the heart. And for me, I didn't like being narrowed down to something. I wanted it to be different and exciting.

So, I started off with a year of surgery, and that was just because I was a year ahead of my wife in medical school so I had the choice between six residency programs, and I sure as heck knew I didn't want to do psychiatry. And so I did general surgery, loved it, they offered me a second year categorical spot. My wife actually told me, she said, you are welcome to do that, congratulations, it may be without me, just because of the personalities and schedules associated with surgery were just not conducive to being an appropriate husband at that point.

Then we moved up here to Kentucky, and I took the year off to study for Step 3, to get everything ready. We didn't want to do a couples match. My wife is med-peds. I ended up just rotating and loved emergency medicine, but my grades didn't support it at that point through Step 1 and Step 2. Well, with Step 3, I boosted my score by forty or fifty points, and all of a sudden I'm attractive in types of rotations, and in residency.

So I got a spot with residency at the University of Kentucky. And to me the reason emergency medicine was, because it fulfilled everything: one, I didn't have to round; two, I didn't have to have a clinic; three, I didn't have a pager, so I wasn't on call, and I got to see a little bit of everything. Every day is different. No matter what kind of setting you're in, every day in emergency medicine is different.

In one room, I may be treating somebody who's in cardiac arrest. In the other room, it's somebody who's dealing with a pregnancy complication. In the other room, somebody with an ankle sprain. And the other room may be somebody with housing insecurity, or a guy having a behavioral health crisis. It's a little bit of everything, and every day is new.

So for me, when we write in our personal statement, “I want to be there for patients and change people's lives,” that's actually what I think emergency medicine is. There's nobody else in the house of medicine that's 24-7, 365, for anybody and everybody, no matter what, that comes in our doors. So that's what really drives me, is just honestly the ability to do the procedures, the variety, the acuity. I mean, I tell my wife now that I could do critical care, emergency medicine, critical care cases, emergency medicine, until I'm the person on the bed, because I love taking care of people. I don't want them to be sick, but if you're going to be sick, or injured, I want you to be in front of me.

So is it perfect? Heck no, it's not. It's stressful. There's a reason why there's so much burnout, and it's one of the number one burnouts. But at the same time, we don't get into medicine because it's easy. If it were easy, they'd pay us twenty bucks an hour and that would be it. We do it because it's hard, and because it takes commitment, because there's stress, and because it's a sacrificial giving to our patient population.

Lindsey Smith

That's a good reminder to our students who may be having a hard time in their first two years to hang in there, because it certainly gets better. And as you mentioned, emergency medicine really kind of sits at that unique intersection of high stakes and constant variety, with no two shifts really ever being the same. So let's talk about today. You run an independent emergency medicine practice, which might be an unfamiliar model to some of our listeners. Can you help us understand how your practice interacts with hospitals?

Ryan Stanton

Yeah, this is an interesting dynamic, because medicine is one of the only places where the people that are the primary focus are the only ones that can't own the hospital. Anybody can own a hospital except the doctors, and so there's always this interesting interaction with the corporate piece of hospital systems, whether it's a small hospital, a single hospital, or whether it's a large system. I work for a large system, the largest in Kentucky.

But within these environments, there's three different really main groups of physician-based models for emergency medicine. One is the employed model, which is growing, where you're just a hospital employee, easy enough, cut and dry, those types of things. Then there is the large group. Some of them are physician-owned, some of them are private equity, some of them are just corporate public companies. And then there's the third group, which is the private democratic group, or physician-owned group.

I work with a group that staffs two emergency departments. We see a total of about 80,000 to 90,000 patients per year. I love this setting because I've worked in all of them at some point. I've done academic, I've done small, medium-sized group, I've done the private-equity-based group, and then I've been with this current group now for thirteen years. And to me, the biggest area of burnout is control: what do I control in my day and in my life? For emergency physicians, the patient care is not the hardest part of it, that's the most interesting and what we got into it for, but it's the outside influences, the metrics, the hoops, the hurdles, the pressures, the insurance games, the payer mix, whatever it may be. But it really boils down to: can I control, do I have ownership, do I have say in my group?

In my group, all the physicians are owners. There is nothing that comes off the top. There's not any special type of money that goes towards the leaders in the group, other than the administrative stipends that go with just doing the work. And so you're involved, there's exposure, there's transparency, there's due process, every one of our physicians has access to the billing data. They all know what I make, I know what they make, I know what they bill, they know what I bill, the patients I see, how I document, all those types of things.

It's very important.

That is my favorite type of group model, that physician ownership, the physician leadership. And we need it not only in our groups, but we need it in our hospitals, we need it in our communities, because there's a special type of skill that comes with being a physician, especially an acute care physician, in terms of the ability to turn chaos into calm and to not get worked up about things. This voice I've got right now, and this type of interaction, is the same interaction I have when there's a code going on around me. It's about staying calm under pressure and bringing that calm into the chaos.

So, that's why I think this type of group is the model for me. Maybe it's not for everybody, but for me it is, because — and I hope that I see it growing within medicine, it is in my region — but we're seeing so many buyouts, sellouts, concerns for consolidation, private equity coming into various levels of medicine, not just emergency medicine. And I think that takes away some of that control and ownership by emergency physicians, or physicians in general. That's unfortunately a loss that too often comes at the cost of the patients and the quality of care for the patients.

Lindsey Smith

Absolutely. That was a really helpful distinction, with the physician ownership model that offers that real autonomy, transparency, and its own set of responsibilities. Let's stay on that responsibility topic. As the EMS medical director for Lexington Fayette Urban County, and the medical director for the American Medical Response and NASCAR safety team, you're responsible for care that happens before a patient ever reaches the hospital. How does that pre-hospital experience shape your thinking about what happens inside the emergency rooms?

Ryan Stanton

I was fortunate enough to be in that early enough track that I got to do the practice track into EMS board certification, so I double-boarded in emergency medicine and EMS, and was very lucky to be one of the last ones to be able to do that. I've always had an interest in the first responder piece of things. I was a volunteer firefighter through college -- very undertrained and very underqualified to do that -- but still was there. I could drive the truck, I had a functional license, which is what mattered. But, coming into the EMS piece, emergency medicine, for so long was the four walls of the emergency department. But emergency medicine and the acute episode of care really is much more in front of that. And I think the entire culture of emergency medicine is evolving to meeting the patients where they are.

I think there's this very close relationship that exists between EMS, first responders, and emergency medicine. And it used to be that most medical directors were just -- if you had an MD, usually at that point, an MD or MD/DO after your name -- you were qualified. And there's still fantastic medical directors that are out there that aren't board certified in emergency medicine. But for me, it really is about the idea that the emergency-medicine-based board-certified training, or residency training, works very well with EMS, just because we do very much the same thing in different settings.

Now, of course, it's different challenges, different opportunities, but it is: how do we interact and how do we improve that care of the patient from the start, from the time they call 911, or the time that they're in need? And that's really about the AMR safety team. Really, what it is, is a call from the drivers to say we want responses on track, from these drivers that have specialty training, experience, and that the drivers can recognize because they see them regularly.

I do the exams at the beginning of the season for a number of these series, and it really is about being there at that moment. The car is still smoking, the things are still just moving a little bit, there's still oil running across the track. And so it is about being there at that moment and being able to provide that immediate response and care, and do that level of stabilization and work before they get to the emergency department, if they even need to go to the emergency department.

EMS, when it first came out, when it first started, truly was the idea that you do the “scoop and run”, where you pick them up and take them to the hospital. And most of those in the early days were from the mortuary, and so it was an ambulance versus a hearse, just depending on the outcome and which direction you were going. But now it's very, very advanced. And with these practitioners, especially with these paramedics and critical care paramedics, there's a lot of opportunity and interaction to get people where they need to be, and get them to the care that they need to be.

So I think it naturally goes together. For me, it's actually loving being there, being out on the road, jumping runs, and being able to be at the scenes and hopefully get people going the right direction even before they get to the walls of a hospital.

Lindsey Smith
I liked what you said there about meeting the patients where they are. And so often I think the outcome in the emergency department is already being shaped on what happens in those first few critical minutes, whether that's on the highway or at 200 miles an hour on a racetrack. You're essentially kind of managing that whole chain of survival, and it sounds like that system-level thinking extends well beyond the clinical setting for you.

So I want to switch gears a little bit and talk about the American College of Emergency Physicians. For our listeners who aren't familiar with it, tell us about ACEP, what role it plays, and what drew you to getting involved at that level.

Ryan Stanton

So ACEP is 38,000 plus board-certified emergency physicians from the United States and beyond. It is the largest organization of emergency medicine in the world. I naturally got involved. I've always been one of those people -- just like with voting -- I can't complain about the people that got elected if I didn't actually make the effort to go vote. The same idea with emergency medicine. I can't complain about the conditions or status of the environment of emergency medicine without actually making an effort to make it better. And not just for me — especially now, when I'm pushing fifty years old — it's the generations that are going to come after me. I've already finished more shifts than I have in front of me. And so how do I make the profession better, so that one day, when I'm a patient, my family's a patient, or whatever, I know that we have the best people there?

As far as getting involved with the American College of Emergency Physicians, initially it was with the PR committee, which is comms now, because of my interest in media and education. Got involved there, ended up as the chair of the PR committee, supported the presidents as they were elected, getting some of the messaging out for the college. And then it's just gone from there.

I started a podcast called ACEP Frontline back in 2015 or so, and have been driving that since then and then ended up getting elected to the board of directors in October of 2019 in Denver, Colorado. Then last year in September in Salt Lake City, I was elected president-elect. And so as of October this year in Chicago, at Scientific Assembly 26, I will be the president of the American College of Emergency Physicians, which basically means that, you know, the primary spokesperson for 38,000 emergency physicians.

We are guided by a council, which is basically almost the Congress of ACEP, and then by a board of directors who then kind of pare that down to strategic priorities and the five pillars that we have for the college. The idea being, is that as the American College of Emergency Physicians, we are the voice and the advocate of the emergency physician, and thus the emergency patient. The idea being that if we improve the opportunities and the environment of emergency physicians, we are going to improve the access and quality of care for emergency patients. 

We're not about a certain group or a type of group, we're not about any business structure outside of that. It really is how do we advocate for emergency physicians and emergency patients?

Lindsey Smith

First of all, congratulations on your presidency appointment at ACEP.

Ryan Stanton

We'll see, we'll see. We don't know for sure yet.

Lindsey Smith

Okay, fingers crossed, fingers crossed. So to play that back a little bit, ACEP is both a professional home for emergency physicians and a policy voice that helps shape the specialty and how it's practiced and even resourced nationally. I think having a seat at the table matters more than ever in today's landscape.

Ryan Stanton

Yes.

Lindsey Smith

So let's talk about some of the urgent issues in emergency medicine. As many of our listeners know from news reports, emergency departments have been under enormous strain in recent years, trying to manage overcrowding, the opioid addiction crisis, the consequences of an under-resourced mental health system, and rising rates of violence against staff, among many other challenges. As you prepare to step into the presidency of ACEP, which of these pressures do you see as the most urgent to tackle?

Ryan Stanton

I think, hands down, the most important one is going to be the reimbursement model. As of 1986-87, we have EMTALA, which means that emergency physicians are obligated and required under federal law to provide an evaluation, medical screening exam, and stabilizing care to every patient. Great legislation. This is anti-dumping legislation, where back in the day in the 1980s, if you were uninsured and an ambulance would call, they would do a “wallet biopsy,” is what we'd call it, and then if you didn't have appropriate coverage or whatever, they would deny you entry. That still exists in many places around the world, but not here in the United States.

For us, it is very important, and something we are proud of, that we are going to take care of every single person that comes to our door. I actually don't even know what kind of insurance people have, or if my patients are insured at all, because I don't care. All I care about is providing the best and equal care, the appropriate care, to every single patient that comes in the door. So it's very important,

But with EMTALA care comes the ability for that to be manipulated. The government payers here, Medicare and Medicaid, don't really pay the bills. Honestly, the rates they pay... when they say 100% Medicare, to everybody else that seems like, well, that's plenty, that's how the doctors are going to get paid. It's actually not even enough to supply the people to be there. It doesn't even keep the lights on. Then you have private insurers, or corporate insurance, or whatever it is, that are always trying to find ways to skip out on the payment, or to skip out on the reimbursement, knowing that we will provide the care, but also then being able to pad their wallet and to boost their profit margin by refusing that payment or cutting that payment. So there's always these whack-a-mole games.

Now we do have the No Surprises Act now, which is very important legislation, with the goal being to take patients out of the middle. It’s no balance billing. If a patient has insurance and their insurance doesn't pay, I can't send them a bill, and I shouldn't. The patient has insurance for a reason, that's a contractual obligation, a relationship with somebody who's supposed to be watching their back and covering the care that they're receiving. They shouldn't be then responsible for payments and stuff on top of that. So we completely support that.

This was the idea of bringing folks to the table, of saying, let’s do baseball-style arbitration: if you refuse how much we're going to get for reimbursement, then we're going to go to arbitration. There's some mediation first, but then go to arbitration, to say, you bring a price, we bring a price, and then an independent entity looks at it, and says “what is the fair value for this care that was provided?”

Right now, physicians are winning 80 to 85% of those, because the rates tend to be severely underpaid, undercut, down-coded, whatever it may be. Of course, the insurers are trying to paint the physicians in a bad light, but at the same time, it's very difficult to paint the physicians in a bad light when you're having to report record profits in the billions every single quarter. It seems like I've not recorded a significant profit in a very long time, and in theory, I'm making less than 50% of what I was making, with inflation adjustment, than I was at the beginning of my career. And so I think reimbursement is huge.

Also, you mentioned the violence. That is huge. That's a big one as well, because we need our nurses, we need our techs, we need our doctors, we need our PAs and NPs to show up to work and feel safe at that workplace. The healthcare environment, especially the emergency department, is the most dangerous, outside of the front lines of a war, in the United States with regard to a workplace. That shouldn't be the case. There should be expectations. Like when you go to an airport, if you go through TSA and threaten them, you don't get to fly. Well, here in the United States, when you come into healthcare, there should be responsibilities for your behaviors and actions towards the people. We understand illnesses, we understand behavioral health crises, but at the same time, there should be expectations of behavior.

I think the consolidation is a huge consideration. We have to start to break down this consolidation. There needs to be competition. In my area, there are really four systems that are competing, it's wonderful, it means everybody's got to up their game. But you have areas in northern Kentucky and East Tennessee where you've had full consolidation, which means less opportunities for the physicians, less opportunities for the nurses and poorer care for the patients. So there's a ton of things, as you mentioned. It is like whack-a-mole.

The reason ACEP is important is, think about Sisyphus pushing the rock up the mountain. As an individual physician, that rock is very heavy and more likely going to run over me. But if I've got 38,000 physicians, we can actually all work together and take that weight off of each other and truly move that rock, and that's what we're doing. It may feel like Sisyphus and that rock with a lot of the efforts that we have, but at the same time, working together, ACEP is truly what moves the needle and gets the audience with those policymakers, so that hopefully we get incremental wins, and day by day hopefully make things better for everybody.

Lindsey Smith

So you mentioned reviewing the reimbursement model, violence against healthcare providers, and why competition between systems is so important in elevating everyone's game and ultimately providing the best care for patients, are at the top of your list to tackle. So we'll be keeping an eye on all of those.

Let's talk now about reaching people with information that matters. As a creator and host of the ACEP Frontline podcast, and chief medical contributor for a local news station, you spend a lot of time communicating directly with the public. What do you think works best in breaking through the noise and reaching people with credible information?

Ryan Stanton

The most important thing for physicians is to bring calm, evidence-based presentations. We saw during COVID what happens when it becomes about influencing as opposed to evidence. It is about being able to treat more than just one room at a time. When I got into media, it really was about...I can take what I do room to room at my emergency department with Central Emergency Physicians, but now I can present that in front of 50,000 viewers or 100,000 viewers, or write something? And the key is, can you be a trusted source?

I still have patients that come up to me in the emergency department and say, you know, you were our voice during COVID. You got us through COVID, because we knew that you were just going to bring the evidence and stay calm and not try to panic people, not to be clickbait. Maybe that's why I'm not, you know, worldwide or anything at this point now, because I'm not into the clickbait. I'm into giving people true information and allowing them then to digest that information to understand what's going on.

I honestly think that's the most important thing physicians can provide, which is information. Voltaire said that the art of medicine is entertaining the patient while nature cures the disease. That's true for eighty to ninety percent of these cases. I'm not going to do anything that changes the outcome, but what I can provide is information. And that's why communication in media, and comms for our organization, are so important... to communicate with the public, with our patients, with our physicians, with other stakeholders, to help them understand what's going on in the emergency department.

Our administrators inside our own building don't understand what happens in the emergency department. It's like they're shocked every time their key works and they get to come through the doors and see what happens in there. So I can't imagine the disconnect between the general public and what we do on a daily basis. Shows like "The Pitt" help. People are like, “it can't really be like that.” Yes, it really is like that. That is my job.

But at the same time, it is that important piece of being those spokespeople. And there's not a ton of physicians that have the skill set or background in media to be able to do some of that connection and communication, but we need that. We need those folks to be there and to be somebody who's trusted.

We've seen recently news stories about those calling out certain government officials with things that they said, or performance, or whatever. If I can anchor in the evidence that's available at the time I make that comment or position, then I can roll back to that and say, hey, this is the best we knew at the time, based on the available information. If I provide an opinion, I need to be able to state that this is my opinion, not based on the science or the evidence, but also understanding that when I look for the evidence and look for the science, I have to be willing to look for all of the evidence and all the science, not just what reaffirms my personal belief, which is kind of that social media view of "doing my research" now, which is the viewpoint that as long as I can find something that agrees with me, I can carry that on as truth.

Lindsey Smith

That's great advice: physicians can provide information, remain calm, be that trusted voice for the public, and ground everything in evidence. I'm also glad you mentioned "The Pitt," because it's a fan favorite of ours over here, and I think it's a great way to portray the realistic everyday of the emergency department.

Before we wrap up today's episode, I want to make sure we've covered everything. Is there anything I didn't ask you that you were hoping we'd have a chance to discuss today?

Ryan Stanton

Yeah, students and those in the process of coming along: there is a place for you in medicine. Find where you fit. For emergency physicians, the majority of us fit very well in emergency medicine. We wouldn't fit in a lot of other places. Interestingly, when my sister-in-law went through the University of Cincinnati, my wife and I sat in the audience at their white coat ceremony - so they haven't even started medical school, they're just getting their white coat -- and as the students went across, we actually picked, based on the way they walked, the way they carried themselves, looks, everything, what profession they were going to be.

Now this is the general category. We're not talking about, you know, pediatric endocrinology, we're talking about the generals. In the end, we came back to the Match Day and we got fifty-five percent of them right. So it's amazing, the personalities and the fit that are in medicine. So make sure that you don't try to fit yourself. Let the medicine fit you and your personality.

I call it finding your “why.” As Mark Twain said, the two most important days in your life are the day you're born and the day you figure out why. And once you find that why in medicine, dive in, and then understand that once you're done with training, the guardrails go wide open. There's a lot of opportunities. Physicians and healthcare professionals aren't just inside a hospital or inside a clinic, there's plenty of opportunities that are out there that need the skill sets and the work ethic and the commitment that you applied to get where you are.

So for me, emergency medicine thankfully has the coolest side hustles of any specialty, but it also fits our ADD personality very well that we have a lot of opportunities. I remind my fellow emergency physicians, when they say, "is there a doctor on the plane” they may not be looking for a podiatrist or a dentist or a veterinarian. They want to see that emergency physician, because they know that no matter the situation, you're ready for that particular situation, then everybody can take that deep breath.

You want to be that person, no matter where you are in medicine, that when they need help or they need answers, they can take that deep breath and relax because you're there. And understand that's the importance of medicine, is that somebody's life and day is better because you're there.

So if there's one phrase I can end with — it's one of my favorite lines from a sermon I heard a decade or so ago — it's that you may not be able to change the world, but you can change somebody's world. And you never know whose world you're going to change just by you being there and having that specialty and that training that you have.

Lindsey Smith

There is a place for you in medicine. Thank you so much for that, and for everything that you've shared today. It's been a great conversation, and I think our listeners are going to come away with a much richer picture of what it means to build a career in emergency medicine at this particular moment in healthcare. Thanks so much for being with us.

Ryan Stanton

Appreciate it.

Lindsey Smith

And that's a wrap on today's episode. A huge thank you to Dr. Stanton for sharing his perspective from the front lines of emergency medicine and for everything he and his colleagues do for patients in their most critical moments. If today's conversation sparked your thinking, we'd love for you to subscribe and share this episode with someone who cares about the future of healthcare. I'm Lindsey Smith. Thanks for checking out today's show. Remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.