key: cord-0073727-saico7r5 authors: Kelly, Maura title: The Looming Jobs Crisis for Emergency Physicians: A New Report Suggests That the Field Will See a Surfeit of 9,400 Emergency Physicians by 2030. Leaders Are Trying to Address the Problem date: 2022-01-19 journal: Ann Emerg Med DOI: 10.1016/j.annemergmed.2021.12.008 sha: c19e24dc876c4b6fedc8de6ba090f35c3d89f26b doc_id: 73727 cord_uid: saico7r5 nan comfort zone caring for the sick." The nurses whom he works with are especially strained because many of their cohort members have left to pursue high-paying travel assignments, leaving added burden on those who have stayed on. More than that, now that vaccines are widely available, caring for patients who have not gotten their shots also presents something of a psychological challenge: "Many frontline workers struggle to sympathize with patients who become ill from Covid when they chose to not receive the vaccine," he said, although ideally, all comers are treated without any added judgment. "If, as projected, we are going to experience another surge in the coming weeks, this will be one more blow to a very vulnerable workforce." Section editors: Truman J. Milling, Jr, MD and Jeremy Faust, MD, MS. Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author has stated that no such relationships exist. The views expressed in News and Perspective are those of the author, and do not reflect the views and ince emergency medicine was recognized as a specialty in 1979, emergency physicians have almost always been more or less guaranteed a good job after residency. Historically, they have been able to work wherever they have wanted to work and to command an appropriate salary. That outlook has started to shift in recent years. In 2019, 20% of emergency medicine residents reported some difficulty finding a job in a preferred geographic area or at a salary they anticipated or wanted, according to data recently released by the American College of Emergency Physicians (ACEP). 1 COVID-19 was part of the problem. Decreased patient volumes during the pandemic wreaked economic havoc, causing many hospitals to cut salaries or staff. These forces came as the job market for emergency physicians was already undergoing a change due to growing trends over the years, particularly an increased reliance on advanced practice providers (APPs) and the proliferation of residency programs-developments that have been driven largely by financial considerations rather than by improving patient care. The ACEP was concerned enough about employment opportunities for its members that, in 2018, it took the lead in assembling a task force to study the problem. Representatives from all of the major national emergency medicine organizations-including the ACEP, the Association of Academic Chairs of Emergency Medicine, and the Council of Residency Directors in Emergency Medicine-spent more than 2 years working on an analysis, released in March 2021, that predicted there will be 10,000 more emergency physicians than positions in hospitalbased EDs by the end of the decade. The ACEP-led task force also began a public discussion about ways to mitigate the problem. Though the debate continues, 5 tactics have emerged as the most popular means for improving job opportunities for emergency physicians in the future. One of the primary concerns of the task force is the growth of residency programs in recent years. At the last count, there were 276 accredited emergency medicine programs, up from 222 in 2015. Most of the growth has come in the past 5 years, according to the ACEP, and although new programs are certainly contributing to the growth, a lot of growth has come from existing programs expanding the sizes of their residency classes. "Some [people] worry, myself included, that . residents and residency programs have been equated to sources of cheaper physician labor," says Chris Bennett, MD, MA, a physician-scientist and Assistant Professor of Emergency Medicine at Stanford University in Palo Alto, CA. Have CMGs fueled the proliferation? That is a common misperception, according to ACEP president Gillian Schmitz, MD. "To start a residency program, you need a sponsoring institution," she says. "Of the 276 existing EM programs, zero have CMG's as sponsoring institutions." Rather, the sponsors are all hospitals and health care systems-who encourage the groups they contract with to start residency programs. "All employment and ownership groups want to keep the hospital happy and they want to keep their contract," says Schmitz. "If the hospital or health system they are contracted with wants to start a residency program, they feel pressured to comply, despite the surplus, to keep their jobs and contracts." But CMGs are not just playing along, if you ask Mark Reiter, MD, MBA, a recent past president of the American Academy of Emergency Medicine, chief executive of the consulting group Emergency Excellence, and director of the emergency medicine residency program at the University of Tennessee Health Science Center in Nashville, TN. While acknowledging that all residencies will have a sponsoring organization, Reiter says that nonetheless, a CMG may be "the driving force" behind starting a new program. Reiter goes on to point out that within a residency program, CMGs are often responsible for hiring, supervising, leadership appointments, staffing levels, the use of APPs, and so on-and they benefit from residency programs in a number of ways. "Residents may make their attendings more productive, especially if clinical work by residents is a higher priority rather than education," he says. "Residents might moonlight at other CMG sites. Residents are good recruits for jobs with the CMG after residency." For hospitals and health care systems, too, residency programs help with recruitment, retention, and staffing-as well as the bottom line. "Hospitals have a financial and business incentive to start these programs," says Schmitz. "Programs can potentially make a lot more money than they're spending, depending on how they negotiate direct and indirect funding for graduate medical education." That is especially true for new community hospitals that have never before had graduate medical education (GME)-also known as "virgin" hospitals. "Universities that had previously established residency programs had their number of GME spots capped decades ago," Schmitz explains. "What people don't realize is that hospitals new to the game of GME have a different set of rules and funding streams. Virgin hospitals have five years to max out their cap and funding on GME spots. Many also receive matching state funding. Emergency medicine is one of the easiest residencies to start. The growth we are now seeing is predominantly in community hospitals that are racing against the clock to take maximum advantage of GME funding within that five-year time frame." Nonprofit and public hospitals have also expanded residency programs. Of the various organizations that have established the most emergency medicine residencies, only 1 of the top 3 is a for-profit system: the Nashville-based behemoth HCA Healthcare-which operates 183 hospitals and more than 300 emergency departments in 21 states-has started 16 new emergency medicine residencies. 2 But the other 2 organizations in the top 3 are nonprofits: Trinity Health, with 10 residencies, and Ascension Health, with 8. All the same, as Reiter points out, some organizations are more profit-driven than others. "Forprofit hospitals and CMG's have a fiduciary duty to their shareholders to maximize profit," he says. "Many nonprofits focus more on other aspects of their mission such as education, service to the needy, and so on." The ACEP task force wants solutions that would elevate patient care and education over profits. (The task force planned to submit recommendations on how to do so to the ACGME and their Residency Review Committee by June 2022). From there, the ACGME will make the final decision about modifications. A top proposal from the task force: making procedural requirements more robust. Currently, physicians in training are expected to do 35 intubations before board certification, up to a third of which can be done on a mannequin. But a number of anesthesiology studies from recent years have suggested that 70 intubations are necessary to reach competence and that even more may be needed to achieve "proficiency." How do emergency medicine leaders feel about raising the bar on requirements? "All discussions about changes in residency training should be done for the educational benefit of residents, not in an effort to decrease supply," says R.J. Sontag, MD, an emergency physician with Mid-Ohio Emergency Services in Columbus, Ohio, and President of the Emergency Medicine Residents' Association. "Where research exists or is completed that shows how changes in procedural requirements will benefit our education, there is no doubt that it will become a mandated part of our residency training." An expert in academic emergency medicine has a similar take. "There has not been great research to determine what defines competency for many aspects of medicine, not just EM," says D. Mark Courtney, MD, MSc, Professor and Executive Vice-Chair, Academic Affairs, Department of Emergency Medicine, University of Texas Southwestern Medical Center in Dallas, TX. "For procedures, it likely is not purely a number. The complexity of those intubations, the varied clinical scenarios, the relative place where the learner starts, the speed in which they adapt to feedback-all may play a role in determining when someone is competent." He adds, "There has been good work in simulation whereby rare procedures can be taught with feedback and thereby provide preparation and in some situations a checklist or standardized approach. With tasks that are primarily cognitive, such as procedural sedation, simulation likely can be a surrogate for case logs. Institutions that have committed to studying the science of education are likely to be the leaders in this, including academic emergency centers with a commitment to teaching, research, and education." Can superfluous new programs be stopped from opening? That is not easy, but the ACEP hopes they can. "We want them to prioritize education over profits," says Schmitz. As this story went to press, the ACEP had communicated its concerns with HCA Healthcare and was working on scheduling other meetings. As Schmitz reports, HCA thought there was a shortage of all physicians. "When we told them that EM is unique-the only specialty without a shortage-at first they were skeptical," says Schmitz. "But they'd been going off data from ten years ago." Schmitz and her colleagues are encouraging them to focus on other specialties and geographical locations that need emergency physicians. They also hope to put pressure on existing programs to expand in a responsible way. (In a statement to Annals, HCA said, "HCA Healthcare hospitals have always been a significant provider of clinical and medical education and have grown residencies across all specialties over the past decade.. We closely monitor physician workforce trends and we adjust our training programs to meet community needs.") About half of all nurse practitioners (NPs) and physician assistants (PAs) who work in EDs now work independently-without the supervision of a physician. "ACEP does not and will not support independent practice," says Schmitz. "We're trying to educate legislators and the public on the difference in our training, skills, and experience-to tell them that it is okay for patients to ask for an emergency physician, to want the most adequately trained person leading the team in the ED." (A recent ACEP poll indicates most people would take the physician option, given a choice: The survey found that patients prefer that a physician treats them if their condition or injury is severe and that nearly 80% of adults trust physicians to deliver their medical care in an emergency, whereas 9% trust NPs and 7% trust PAs.) 3 Promoting a physician-led model seems to be popular not only with emergency physicians but with experts who study the field. "Given the cost-containment pressure from payers and hospitals, the penetration of APP in EM clinician market will likely accelerate, rather than decelerate, in the future," says Ge Bai, PhD, CPA, Associate Professor of Accounting, Johns Hopkins Carey Business School, and Associate Professor of Health Policy and Management (Joint), Johns Hopkins Bloomberg School of Public Health. "Therefore, physicians must act strategically to coexist with APPs and, in the meantime, preserve and even expand the value uniquely created by physicians." So far, however, that has proven somewhat difficult. In as many as 30 states, NPs and PAs have gone to court to win the right to practice independently-and, in some instances, they have won. "We've joined with the American Medical Association Scope of Practice Partnership to fight this," says Schmitz. "We testified during trials in numerous states like Texas and Louisiana. 4,5 Through our advocacy, in conjunction with the state medical associations, we overturned some legislation that allowed NPs and PAs to practice independently. But we have lost some battles in states like California." As Schmitz notes, the scope of practice is defined and legislated at a state level. "This is a state battle," she adds. "We need chapters and members to advocate." Stanford's Christopher Bennett points out that insisting on physicianled care also presents a practical problem. "There are already vast regions of the country where you just do not have access to EPs-either historically or at current," he says. Indeed, although there could well be a surplus of emergency physicians overall within the decade, the number of practicing emergency physicians in rural areas across the United States has long been in decline-exacerbating the existing problem of emergency physician "deserts" in parts of the country. "This absence of access to EPs has arguably spurred the use of alternative forms of care-both telehealth and non-physician providers," Bennett notes. So although he thinks promoting a physician-led model is crucial, he questions whether emergency physicians will be available to lead EDs throughout the country, particularly in low-density areas. "I don't know if we can honestly say that we have the ability to ensure ubiquitous access to EPs at current," he says. "I don't know at what point in the future we will be able to say that." Bennett's concerns point to another pillar of the ACEP-led push: finding ways to encourage emergency physicians to work in rural and low-density areas. In those areas, as he notes, the demand for emergency physicians is still quite high. "Further," he adds, "compared to urban emergency physicians, rural emergency physicians are notably older than their urban counterparts." When those aging doctors retire, if trends continue unabated, they are unlikely to be replaced, both because hospitals in those areas have been closing and because other emergency physicians are not interested in moving to isolated spots, where opportunities and amenities tend to be lower. The ACEP hopes it can find ways to nudge emergency physicians to areas where they are needed. "We have to look at the barriers," says ACEP's Schmitz. To that end, she and her peers are exploring a variety of ideas, including loan forgiveness, expanding residency rotations in rural areas, and generally encouraging and preparing residents to practice in resource-poor locations. Another element that the ACEPled group sees as crucial: furthering the specialty's reach. In developing this approach, the field of anesthesiology may be a model. "Anesthesia had a projected surplus of physicians years ago," Schmitz points out. To mitigate the expected excess, they moved beyond the airway and into pain management. "That was very successful for them," says Schmitz. "So we're looking at expanding too-into telemedicine, post-acute care, proceduralists, critical care medicine, free-standing and hybrid delivery models; new ways to use our skills outside the four walls of a hospital." Indeed, if emergency physicians' skills are not sufficiently in demand in EDs themselves, then bringing them to settings where they are could solve many problems. Section editors: Truman J. Milling, Jr, MD, and Jeremy Faust, MD, MS Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author has stated that no such relationships exist. The views expressed in News and Perspective are those of the authors, and do not reflect the views and opinions of the American College of Emergency Physicians or the editorial board of Annals of Emergency Medicine. American College of Emergency Physicians American College of Emergency Physicians 21-poll-adultsconsider-247-access-to-the-er-essentialprefer-care-led-by-physicians-in-a-crisis 4. 8 states defeat efforts to expand APRN scope of practice. Robeznieks A. Accessed Louisiana Scores Important Scope of Practice Win. American College of Emergency Physicians