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In January, when Jeff Chien told Allan Kamara that he thought he was going to be fired from the Santa Clara Valley Medical Center emergency department, where they worked, Kamara thought his colleague was being paranoid.
After all, as the ER’s medical director, Chien was a legend, someone about whom everybody spoke in reverential terms. Santa Clara Valley Medical Center in San Jose, California, often referred to as VMC, was the sort of place where violent assault at the hands of patients was a near-daily occurrence. Kamara, a nine-year ER nurse at the facility, had watched the 300-employee department chew up and spit out plenty of lackadaisical suburban doctors, and when he worked his first shift with Chien in 2016, he did not have high hopes. Twelve hours later, he was a believer.
“A multiple major trauma would come through the door, and you would be just mesmerized by the way he would conduct this… theater of organized care,” said Kamara. “When he delegates, because he mixes his delegation with utmost humility, even if you don’t want to do what he’s telling you to do, you will find yourself doing it with passion.”
But Chien’s fear turned out to be correct. On January 14, US Acute Care Solutions, the private equity-backed physician staffing monolith that had taken over the hospital’s ER contract last June, sacked everyone’s favorite boss — with a cruel twist. The Ohio-based contract management group, which emergency doctors refer to by the acronym USACS, fired Chien as medical director, but kept him on the schedule as a doctor. So Chien continued to show up to work because, as someone who had basically been fired for no apparent reason, he seemed scared not to.
Chien declined to comment for this story. But Kamara says the physician's treatment was just one of many ways USACS has wreaked havoc on the facility. “You need to understand, these are young doctors who are full of energy and dedication,” he said. “But the day after the first meeting with USACS… you have never seen such young, energetic doctors so disillusioned and demoralized.”
It’s why Kamara, who leads the Registered Nurses Professional Association, the labor union for county-employed nurses, helped VMC’s ER doctors do something no other physicians like them had ever attempted to do: organize.
The doctors, with Kamara’s help, wrote letters to hospital leadership and the board of supervisors detailing some of what they believe to be USACS’ worst abuses. They enlisted more than 200 VMC employees to sign a letter formally protesting the ouster of their boss. They showed up at county board of supervisor meetings, pushing to terminate its contract with the private equity group. And on January 25, they staged a “walkout” to protest the private equitization of their profession, waving signs saying “WE CAN’T TRUST USACS” and “WE NEED A STRONG TEAM.”
In response to an interview request, USACS sent a statement attributed to Chief Clinical Officer Matt Patlovany that noted, “USACS is proud to be a physician-owned leader in emergency medicine, hospitalist, critical care and observation services, aligning with health systems across the country — including in Santa Clara where we’re actively working to address certain concerns onsite with our team.”
So far, the physicians’ efforts at VMC have yielded limited returns — but they are symbolic of a sea change underway in how many doctors view their role in the country’s ever-more-voracious for-profit health care system. That’s especially true of doctors working in emergency medicine.
Not long ago, ER doctors prized their unique ability to ignore both politics and profits, and treat patients in order of the severity of their condition, regardless of their insurance status. But companies like USACS changed all that. Over the past decade, the percentage of ER doctors working for small independent practices has shrunk by more than half to just 20 percent, and the corporate consolidations have led physician wages to stagnate even as billing surged. Then came COVID-19, which caused an abrupt plunge in ER traffic that left many doctors temporarily downsized at the very moment their skills were needed most.
Across the country, many ER doctors are privately arriving at the same conclusion that inspired the USACS uprising: It’s no longer enough to help people by treating one ER patient at a time, when the real emergency appears to be unbridled corporate greed.
As one VMC doctor put it, “If we’re going to have health care for profit, and that’s not how I would design a health care system, but if this is the way it’s going to be, we need a union.”
“This Is The Public’s Hospital, And The Public Deserves To Know”
It is an almost universally acknowledged truth in 2022 that our health care heroes are not okay. COVID-19 unleashed a million forms of chaos on an already stressed collection of health facilities, whose leadership for the most part responded by telling workers to do more with less — and to keep quiet about it.
At the time of the USACS takeover of the physician contract for VMC’s emergency department last summer, Kamara had been preoccupied with his own campaign to convince local officials to move more aggressively to fill the hundreds of open nursing positions at VMC and its satellite locations, because the onslaught of back-to-back-to-back understaffed shifts had brought his members to their boiling point.
But he also knew he and his colleagues were relatively lucky to belong to the 17 percent of nurses who are in a labor union, working at one of the 18 percent of American hospitals that was still government-owned.
The doctors didn’t share those advantages, and after Dr. Chien’s semi-firing, Kamara came to the conclusion that the staff’s predicament was far more dire. USACS, he realized, was profiting from their misery.
Consulting payroll records, one doctor discovered the ER had treated almost 1,000 more patients in December 2021 than it had the year earlier, despite logging 50 fewer physician assistant shifts. This meant the doctors had handled a 20 percent surge in patients with a 40 percent reduction in assistants. The physicians said they had done so by trying to avoid going to the bathroom, staying hours after the technical end of their shifts, and begrudgingly making patients wait even longer before receiving care.
As a result, say VMC employees, patients who weren’t bleeding to death or having a stroke were having to wait all day to see someone. One physician reported laying awake at night wondering if they might have been able to salvage an appendage that required amputation, if only a doctor had been available sooner.
At the same time, wages were being cut so drastically that on certain shifts, physicians were making less per hour than the average nurse there, with none of the county benefits like generous pension funds that often kept nurses from bolting for cushier gigs.
USACS, Kamara and his colleagues learned, was getting paid a flat fee to staff the ER. That meant that every time the company let shifts go unfilled or cut doctors’ hourly pay, they were pocketing the difference.
Complicating matters, USACS had a reputation for blacklisting or attacking doctors who questioned safety standards or reported unsafe practices. And since the job market for ER docs was notoriously punishing, none of the physicians wanted to make an enemy of USACS.
So Kamara agreed to do it for them. He circulated a petition to reinstate Dr. Chien that won the signatures of 217 ER employees, and stacked his schedule with meetings with hospital administration and county commissioners to try to convince them to part ways with USACS.
VMC physicians, meanwhile, sent multiple emails to the hospital’s CEO and county supervisors detailing the numerous areas in which they had allegedly violated their contract or state law. According to the emails, that included paying physicians only $121 an hour for treating jail inmates, nearly $70 less than apparently specified in contract, as well as forcing VMC employees to sign non-compete agreements, even though such agreements are illegal in California.
Finally, Kamara convinced the doctors to plan the thing they had spent months wondering whether they could pull off: A staff “walkout” to protest cost cuts and corporate greed.
“Leading a union that is working for the public, there are times when you have to let the public know what is happening,” said Kamara, who emigrated from Sierra Leone in his early twenties. “This is the public’s hospital, and the public deserves to know why their loved ones are waiting 14 hours in the waiting room.”
Technically, it wasn’t a real walkout. Most doctors interviewed said they were not sure walking off the job would be legal. Fifteen years ago, a New York nursing home boss successfully convinced a district attorney to indict 10 nurses who had walked out in protest of short-staffing and pay cuts on charges of patient endangerment and conspiracy.
So on the day of the rally, none of the USACS-employed doctors who were working that day left the ER. Instead, two dozen nurses and support staffers walked out, along with a handful of physicians who were on their day off. They carried protest signs and spoke to a reporter from the San José Spotlight about the “chaos” that had accompanied Dr. Chien’s termination.
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