When the 2009 ACEP workforce study was published, emergency physicians were expected to remain in high demand indefinitely. A sense of complacency set in.
Game-changing developments have taken place since then. Thomas Cook, MD, recognizes the rising competition from PAs and the increasing number of residency programs. (“The Invasion of the PAs,” EMN. 2019;41:1; http://bit.ly/37ZBQOv.) The kill shot is the employed physician model, which puts hospitals and large contract groups in the driver's seat. This is a self-inflicted wound.
Dr. Cook's observation of the anesthesiologist scheme to use NPs to increase revenue was not lost on emergency groups. Doctors who would never work side by side with an experienced non-residency-trained physician are all too happy to let PAs practice. Initially, the standard was FACEP, then eventually ABEM certification regardless of experience. In most but not all instances, these grandfathers were allowed to continue practicing where they had privileges, but could not change practice sites.
Rural medicine was essentially abandoned and left to find its own solutions. Anesthesiologists recognized in the 1990s that they were overproducing residents and cut programs severely. This remedy is no longer available. The increased number of trainees and competition from PAs and nurse practitioners will drive the market and dictate compensation. By Dr. Cook's own numbers, two PAs still cost a fraction of one emergency physician.
I am long retired. I held two hospital contracts from 1981 to 1983, then entered the Air Force and a career in emergency medicine at one hospital for 30 years. I was a medical director, chief of staff, the president of a state chapter of ACEP, and a legacy fellow of ACEP. The majority, if not all, of you would surely insist that I was a physician who worked in an ED but never an emergency physician, so forgive me a large dose of schadenfreude as I watch this saga play out.
Timothy Donnelly, MD
Dr. Cook responds: Thanks for sharing your experiences about the emergency physician workforce from your time in practice. I cherish the opinions of those physicians who grandfathered into emergency medicine, and several of them were faculty members in my residency. Today's emergency medicine residents do not understand the importance of the contributions all of you made to their future careers.
Nonetheless, I am also grateful that we managed to standardize the training of our specialty to make it the juggernaut it is today. As Greg Henry, MD, a past ACEP president, once said, “We took the scraps of medicine and made them into pâté.” The entire process was clumsy at times, and there were casualties. Folks dedicated to the practice of emergency medicine were subject to new standards they could never achieve because of their station in life.