Letter to the Editor
While our colleagues in Congress debate the future of Medicare and the Patient Protection and Affordable Care Act (PPACA), emergency physicians must address our own imminent crisis: workforce.
While emergency departments are closing and patient visits are climbing, EDs have become the main source of health care for a growing segment of the U.S. population that lacks access to primary care services. EDs (which account for only four percent of the physician workforce) handle 28 percent of acute care visits. And EDs treat a disproportionate share of uninsured patients compared with other sites. The dramatic increase in emergency department use during the past several years has been driven in large part, by the chronic shortage of primary care physicians.
The critical condition of primary care has been well described. The American Academy of Family Physicians predicts that the shortage of family physicians will reach 40,000 by the year 2020. Similarly, primary pediatric care is in a state of crisis. And a 2006 report by the American College of Physicians states that while there is a growing demand for primary care due to growth in the number of people with chronic diseases and long-term care needs of an aging population, there has been a decline in the number of medical students entering primary care. The authors state that primary care, “the backbone of the nation's health care system, is at grave risk of collapse due to a dysfunctional financing and delivery system.”
Compounding the problem of shifting primary care to the nation's EDs is the profound national shortage of emergency physicians. A study by Carlos Camargo, MD, of Harvard Medical School and the Harvard School of Public Health found that the supply of emergency physicians might never reach the increasing demand for their services. The Institute of Medicine has concluded that emergency departments and ambulatory services are overburdened, underfunded, and highly fragmented. Patients face long waits in crowded EDs, and they often need on-call specialists who are not available. A significant contributing factor is that more and more patients are turning to emergency departments for care because they lack insurance, they need after-hours care, or because of their limited medical options in rural communities.
An unintended, if not unanticipated, consequence of the PPACA is that it will likely result in further crowding of EDs. It is anticipated that ED waiting times will continue to rise above already unsafe levels.
The data that show a geographic maldistribution of physicians are also compelling. Data from 2008 show that there were 10.3 EPs per 100,000 people in urban areas versus 2.3-5.3 for rural settings. If and when there is an adequate number of EPs to staff all of the nation's EDs, there will still be a maldistribution of physicians.
However we choose to address our challenges in workforce, we must not dither. As a community of colleagues and humanitarians, we must do first what is best for our patients, and next what is best for the society as a whole. This is not about us but about future generations: our children and their children. As a professor of mine once cautioned, “We must not follow our patients, we must lead them.” Similarly EPs must not follow health care issues; we must lead them.
David M. Lemonick, MD