Can Emergency Medicine be Unified?

Abstract

Figure: emergency medicine, ACEP, AAEM, emergency physicians, American College of Emergency Physicians, American Academy of Emergency Medicine, CMGs, demographics, private equity, consolidationFigureEmergency physicians are strong-willed, smart, distractible, and accustomed to being in charge, but we're a bit like herding cats—challenging to unite. Nonetheless, our professional organizations are tasked with solving the problems of our specialty by uniting physicians with common goals. Understanding why physicians join or leave these organizations, specifically, why the physicians on the cusp are thinking of changing their membership status, is crucial to broadening organizational appeal and identifying unifying concerns. Physicians with strong opinions—positive or negative—about specific professional organizations are not likely to be on the cusp of changing membership status. Members and non-members on the margins, however, are potentially high-yield targets for gaining or retaining members. Recognizing the concerns of this group may be key to a professional organization's success. So, I decided to look at the American College of Emergency Physicians and the American Academy of Emergency Medicine. Importance of the Margin “This is exactly what the net promoter score is,” said Mollie Pillman, ACEP's senior vice president of membership engagement. “The theory behind it is that you have your promoters, your detractors, and your passives in the middle, and you really want to go after the passives because they're the ones whose minds you'll be able to change.” ACEP's Executive Director Sue Sedory agreed, noting that the margin is key for the specialty to stay strong. “If we can get more people who just want to engage and have a stake in the future of the specialty and then help them one by one, which is what our commitment has been, [that] is really key.” AAEM's president, Jonathan Jones, MD, said it's easy to attract people who already agree with you, but that he didn't want members just for members' sake. “What I do want is people that believe in our basic principles but have a different perspective, that have a different background, that have a different plan.” ACEP and AAEM said they recognize the need for a more granular understanding of marginal members and non-members, but neither engages in mathematical modeling of this problem. “We are about nine to 10 months into association analytics implementation, which is a platform built for associations that pulls in all of your data from events and from finance and from the membership database, and it consolidates all of it together,” Ms. Sedory said. “So hopefully we'll be able to answer that better in the future.” AAEM has yet to invest in such a system either, though it is something the academy has considered. Both organizations said they also recognize the importance of incorporating a diversity of opinions. “ACEP is taking proactive steps to integrate member and non-member feedback into its strategic planning process, evaluation of new offerings, and communication effectiveness,” the college said in a statement. “We regularly conduct focus groups which are carefully chosen to represent a wide range of demographics and perspectives, and test new ideas and benefits with diverse groups before they are made available to a wider audience.” Dr. Jones said AAEM strives not to become stuck in its own bubble by reaching out to physicians in academia, CMGs, and democratic groups. “If we have people from different practice environments, that's the best way that we can try not to become an echo chamber,” he said. “And obviously we want a diverse membership, not just from practice environments but geographically [and by] gender and race.” Proof of Concept I recently surveyed emergency physicians on Facebook about their thoughts on professional organizations. The total response number was low, just more than 100, which is not nearly high enough to generalize about emergency physician preferences. Selection bias was also a real concern with a smaller group acquired this way. My intent with these data was not generalization, however, but to demonstrate how a professional organization might assess their marginal members and non-members. If a group this size can be effectively segmented with a relatively small amount of data, then the same thing can be done more easily and effectively with larger sample sizes and larger amounts of data. I segmented the group based on a specific question: How much do you value membership in your professional organizations? I used k-medoids clustering (an unsupervised machine learning process that breaks data into k clusters by iteratively picking samples within data to serve as the cluster's best median, making it more robust to outliers than the similar k-means clustering process) to sort respondents into detractors (respondents who view the organization very poorly), promoters (respondents who view the organization very positively), and passives. I asked about the issues that professional organizations should prioritize more to see if there were differences of opinions based on the perceived value cluster allocation. These topics were selected based on feedback from interviewees and ACEP's latest annual report. Respondents had specific concerns (some different, some the same) about ACEP and AAEM that are more pressing for passives or marginal members than for other clusters. I ran a two-way ordinal analysis of variance testing of ACEP and AAEM clustering to confirm statistical significance on the (visible) differences. Marginal members of both organizations considered corporate consolidation and private equity in medicine to be an issue deserving of more attention.FigureI then flipped the tables and used only the respondents' age and their responses to the priority questions to determine how far apart respondents were using a metric called the Gower distance (to account for the ordinal data of the Likert scale). I chose to use three clusters (based on maximization of a metric called the silhouette width; this assesses the uniqueness of the clusters), and used a similar process to k-medoids clustering to form groups of respondents based only on what priorities they considered important, this time without knowledge of membership status or value. Clustering was able to sort respondents into groups that seemed to favor AAEM membership (cluster 1), favor ACEP membership (cluster 2), or eschew both organizations (cluster 3). Average perceived value of the organizations also followed this characterization. Cluster 1 valued AAEM membership the most and ACEP membership second, and the opposite was true for cluster 2. A United Specialty Both ACEP and AAEM report caring a great deal about members who may be on the margins; there are ways to find these members and determine what matters most to them. If organizations want to avoid becoming entrenched echo chambers, they must actively seek out marginal members and non-members and attempt to incorporate them in meaningful ways. A united specialty is clearly important, but marginal members do not want the same things as their nonmarginal counterparts; it is the responsibility of our professional societies to achieve real unity in critical areas by meaningfully incorporating the differences of opinion of others. There is likely a subset of physicians who is generally disenchanted, but ACEP's marginal population appears to be AAEM members and vice versa. This paints a hopeful picture in my mind: Reaching out and incorporating those with different ideas may be easier than we think. Even for emergency physicians. DR. BELANGER is the chief data officer of TotalCare (totalcare.us), the chair-elect of the American College of Emergency Physicians Workforce Section, and an emergency physician in McKinney, TX.