Skeleton Crew

Carl Montgomery outside Tennova Healthcare Hospital in Cleveland, Tennessee / REBECCA TORRENCE

Even those on the front lines aren’t immune to the financial casualties of COVID-19. Dozens of healthcare workers at an emergency room in southeast Tennessee receive devastating cuts to their salaries—but the real cost could be the lives of their patients.

When 26-year-old Carl Montgomery comes home from work, he immediately strips down, showers, and washes his uniform. He’ll pick up his N95 mask, which he left behind, when he returns tomorrow. He makes sure not to come into contact with anyone. He knows that, working in an emergency room during the COVID-19 crisis, his life is at risk.

Yet his primary concerns aren’t about his own wellbeing. They’re about the wellbeing of his patients. And Carl believes his hospital is putting those patients in danger.

Carl had been working as a scribe at Tennova Healthcare in Cleveland, Tennessee, for five years—the last three, as Chief Medical Scribe, managing a team of ten other scribes—when on March 25, at 11:00 a.m., he woke up to a text from one of the physicians, which read: “Have you checked your email? Apparently, scribes will be unemployed in five days.”

Scribes are crucial to the efficiency of the ER. As a physician examines a patient, the scribe stands back and logs the patient’s information, including their vitals and their symptoms. This way, the physician can focus on caring for the patient. With scribes, a physician at Tennova can see an average of 1.8 patients an hour. Without scribes, that average is 1.5.

Firing all scribes certainly threatens a physician’s ability to provide quality patient care. But for Carl, the relationship between a physician and scribe is more than just professional—it’s personal, too. “When you’re working with a doctor, you’re with them all day,” Carl explains. “You see patients together, you go to the cafeteria together, you walk between rooms together. After so many shifts, you develop a relationship with them.”

That comradery hasn’t always come naturally to Carl. Tall and toned, with mousy brown hair and an eagerness in his thick southern drawl, he doesn’t seem like the shy type—but he claims he was quiet and overwhelmed during his first three months in the ER. In the middle of his orientation of the hospital, he ran into a physician who introduced himself to Carl by his first name. “That was so weird to me,” recalls Carl. “I thought, ‘That’s not your name. Your name is Doctor.’”

After few months of working in the hospital, however, Carl was no longer intimidated. “You realize they’re just people, like you and me. They have families, they joke around, they get upset. There’s not one of them I don’t have a relationship with,” he says.

Those relationships extend beyond the ER. “I have house-sat for them, gotten drinks with them, and gone on trips with them. I consider a lot of them to be my friends,” Carl admits, affection filling his voice. But saving lives together requires more than friendship—it demands faith, which Carl says he feels amongst his team. “I trust them, and they trust me,” he says.

That mutual trust has allowed Carl to commiserate with the other healthcare workers at Tennova—because the scribes weren’t the only targets of these changes. The doctors themselves saw an 11% cut in their hours, from 36 to 32 hours of coverage a day. Perhaps the most dangerous cuts were made to the Advanced Practice Clinicians (APCs), a term that encompasses non-physician healthcare providers like Nurse Practitioners and Physician Assistants. Their hours were decreased from 46 to 33 hours a day—a 38% cut.

Angela*, one of the APCs, has felt the full force of these cuts. A single mom who also supports her elderly parents, she feels defeated by these seemingly irrational changes. While patient volumes at Tennova have decreased due to Tennessee’s Stay-At-Home Order, she thinks the cuts were made far too hastily. “It’s a knee-jerk reaction for something we don’t know a lot about. The volumes will obviously come back when the stay-at-home order is lifted,” she argues. As Carl contends, “they were quick to take away hours, but it’ll be a lot harder to get them to add those hours back.”

“They” are American Physician Partners (APP), the corporate group that provides physicians, APCs, and scribes to Tennova. While APP doesn’t own Tennova, the hospital operators have yet to respond to these changes. APP is essentially operating with unlimited power over their employees.

Angela affirms that these decisions have worsened the hospital environment. “Morale is down. Everyone is angry. I do feel respected by the people working with me in the hospital—but I don’t feel respected by APP.”

Yet that perceived disrespect would only escalate in the following days. After March 25, hospital employees were scrambling to process the personal changes they’d have to make in response to what they thought was the worst possible outcome. But APP wasn’t finished making cuts. On April 2, the APC’s hours were cut from 33 to 29 hours a day. APP also indefinitely deferred 10% of the physician’s salaries. And two weeks later, APC hours were cut from 29 to 21 hours a day. That’s a 55% cut from their original salaries.

The APCs are now at an extraordinary risk of financial distress. Many of them have children. Some, like Angela, are single parents. Several are still paying off their student loans. Like everyone else, they live according to their paycheck—and suddenly slicing that paycheck in half threatens their livelihood. “If people are only working half their normal hours, there’s no way they can pay their bills,” Angela contends.

Yet despite these financial concerns, the core apprehensions of these Tennova employees lie with their patients. “You can’t effectively run an ER with these hours,” Angela says. “I feel scared for our patients.” The changes, according to Angela, are “completely preventing (Tennova employees) from providing good patient care. It’s frustrating, and it’s dangerous.”

Carl Montgomery’s name card as a Tennova Healthcare employee / REBECCA TORRENCE


Carl and Angela both express concerns over working with a “skeleton crew,” an ominous term that references their new normal. With so few healthcare employees present at any given time, they’re working with bare bones to provide for their patients. And even the word “crew” is generous. With these new changes, there are three hours a day without a single APC present. During those three hours, the physician is the only healthcare provider in the entire 44-bed ER.

Carl says these new staffing cuts pose unnecessary risks to patients, and at a potentially fatal cost. “We’re gambling, hoping that any critical patients will come in at a very convenient schedule. But that’s not how emergency rooms work,” Carl sighs. His next words sound desperate, defeated. “It feels like every day we’re rolling the dice.”

The scribes were perhaps the only employees to receive bittersweet—instead of simply bitter—news. On March 28, the scribe program was extended. But soon after, APP announced that they would no longer be paying the scribes. If any physician wanted to work with a scribe, they could pay the scribe themselves. $20 an hour, out of the doctor’s own paycheck.

Carl calls this decision “ridiculous.” Not only are the physicians receiving cuts to their hours and a 10% deferment of their salary, their salary will now decrease again if they choose to work with a scribe. “It’s baffling to me, and baffling to all the providers how they’re being treated,” Carl asserts. “In a perfect world, you should be increasing provider pay right now. It’s so inconsiderate.”

And it’s not as if the physicians haven’t tried to fight these changes. Two weeks after the initial cuts, they returned to meet with APP again—this time, with a list of demands. In addition to requesting benefits for Tennova employees, the physicians presented APP with a step-by-step plan to resume normal staffing hours after patient volumes inevitably increase.

Yet their efforts were in vain. Not only did APP reject these suggestions, they responded with a thinly veiled threat to fire any dissidents. As Angela reveals, “they basically told us, ‘if you don’t like it, you can leave. Just let us know.’” The message was clear: Speak out against APP, and your career at Tennova is over.

This exchange reveals a core issue with private healthcare in the US. Tennova is a private hospital, meaning their brand of healthcare is for-profit. If that sounds like an oxymoron, it’s because it usually is. In the world of private healthcare, quality care can only be sustained as long as the hospital continues to profit. And to minimize a hospital’s losses, patient and physician well-being is considered a necessary sacrifice.

Luckily, these changes haven’t put Carl at significant financial risk. He has plans to attend Lincoln Memorial University as part of their Physician Assistant (PA) program, starting in October. “Even if I stopped working next month, I’m okay to pay my bills until then,” he acknowledges. Yet Carl knows that not all of the scribes had a contingency plan. “These people have to find another job or file for unemployment, because they can’t just stop having income,” he emphasizes. Now, with their fate completely in the hands of the physicians, the scribes’ financial futures are tenuous at best.

APP’s many callous actions are especially unjust for employees risking their lives at the front lines of the COVID-19 crisis. But though working in an emergency room during a pandemic could endanger their health, the healthcare workers at Tennova don’t seem to be preoccupied with their own safety. Instead, they’re concerned for their families. “I’m less scared for myself—I signed up for this,” Angela stresses. “But my family did not.”

Carl has two great aunts, who he calls Aunt Ethel and Nana, both in their 80s. “They’ve pretty much been my mother figures,” he says. After Carl’s mother passed away during his junior year of high school, the sisters stepped up to take care of him, both emotionally and financially. But because of his job, Carl now takes extra precautions around them. Normally, he would bring Ethel to her doctor’s appointments and take her grocery shopping. Now, he buys her groceries and sets them inside her house, alone. “I just can’t be around them anymore,” he says.

Ethel and Nana still check up on Carl with concerns about his health. “They call me after work sometimes, worried about me,” he says. But Carl believes that worry is misplaced. “I’m not concerned about myself,” he asserts. “But I’ve definitely been concerned about them. And I’m not taking any chances.”

Despite Aunt Ethel and Nana’s apprehension, Carl hasn’t wavered in his plans to pursue a career in medicine. “I just can’t see myself working in another field,” he says. “I love working in the ER.” But while APP’s actions over the past two months may not have dissuaded his career goals entirely, they have certainly altered his trajectory. As Carl approaches the beginning of his Physician Assistant training in the fall, he reflects on what he now wants in a future employer — and what he doesn’t. “Whenever I do start working as a PA, this experience has put a bad taste in my mouth about working for a big corporation,” he says. “And when I do go to sign a contract, I’m going to pay attention to everything that goes into it.”

In the end, no amount of attention to their contracts could have saved these Tennova employees. APP has rendered the contracts void—and there’s nothing the healthcare workers can do about it. “They have their employees in a bind, and they know it,” Carl contends. “These people have worked in medicine for so many years. To treat them like this is disgraceful.”

The extensive medical experience of all of Tennova’s employees has led them to this pivotal moment in our global history. At a private hospital, however, patient health and provider wellbeing are only as important as the company’s bottom line. COVID-19 hasn’t changed that. According to Carl, APP’s actions have revealed the ugly truth about working for a healthcare corporation—“At the end of the day, you’re just a number.” •

*Name changed to project subject privacy.