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Most EM Groups On Board with Workforce Study, but AAEM Takes Issue with ACEP Leading the Pack

Sorelle, Ruth MPH

doi: 10.1097/01.EEM.0000657616.86081.7a
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    workforce, job market, advanced practice providers, emergency medicine, residency

    What does the future of emergency medicine look like as EPs face a changing job market and health care landscape? That's what a new workforce study will try to answer.

    Paul Kivela, MD, the immediate past president of the American College of Emergency Physicians, appointed a board-level group in 2018 to discuss how to go about the study, and that group suggested a multiorganizational task force to assess the current and future emergency medicine workforce at a cost of $8,000 per organization.

    The group chose Edward Salsberg, the director of Health Workforce Studies at the Health Workforce Institute at George Washington University, and his team to conduct literature reviews, data collection, analysis, and interviews to make projections about the future of emergency medicine. He will present the final report at the annual ACEP meeting in October.

    An ACEP spokesperson said in a statement that the analysis will examine the role of the emergency physician, address disparities in rural care, and inform strategies to work collaboratively with advanced practice provider organizations. Participants include representatives from the American Academy of Emergency Nurse Practitioners (non-voting member), the American Board of Emergency Medicine, ACEP, the American College of Osteopathic Emergency Physicians, the American Osteopathic Board of Emergency Medicine, the Council of Emergency Medicine Residency Directors, the Emergency Medicine Residents Association, the Society for Academic Emergency Medicine, and the Society of Emergency Medicine Physician Assistants (non-voting member). The Association of Academic Chairs of Emergency Medicine, the American Academy of Emergency Medicine, the AAEM Resident and Student Association, and SAEM's Residents and Medical Students group elected not to participate.

    Contract Management

    David Farcy, MD, the president of AAEM, said the academy balked at the cost to join the task force. “We didn't think it was fair to use the money in that way,” he said. “Membership money could be better used on lobbying and other issues that are more important at the moment.”

    Dr. Farcy said Mark Reiter, MD, a past president of AAEM, recently completed a workforce study, and the academy issued a position statement that said, “AAEM is concerned with the rapid growth in the emergency medicine workforce, fueled by the accelerating growth in emergency medicine residences, as well as the increasing number of advanced practice providers.”

    The position statement also said the organization is concerned that “most new emergency medicine residencies are sponsored by national contract management or by national hospital networks that may have a vested interest in creating an oversupply of emergency physicians.” The group suggested working with the Accreditation Council on Graduate Medical Education to make changes that will target growth in the emergency medicine supply to match growth in emergency department patients.

    “One of AAEM's big concerns with ACEP taking the lead on the workforce study is that the leadership of ACEP has also been the leadership of contract medical groups,” said Dr. Farcy. “The last three to five presidents have had financial ties to one of the contract medical groups.”

    AAEM also worries that its voice would not be respected or heard, Dr. Farcy said. “We have participated on many task forces such as sepsis, pain, wellness,” he said. “Will this task force take on the crisis in rural health care?”

    On the Rise

    Mr. Salsberg, who said he could not discuss the specifics of the research, said his plan involves a global look at the issues facing emergency medicine and how that will affect the need for emergency physicians, including the shortage of EPs in rural areas. “Physicians are willing to go to the major cities with training programs to make more money,” he said. “Smaller communities need to pay more to attract [those] in their 20s or 30s who has debt and a lifestyle more attuned to an area where they trained. It is not simply do we have enough? Do we have enough in the right places? The main goal of the study is to help the specialty understand where they are in terms of history and whether they should continue to grow.”

    The two key elements affecting the supply of EPs are how long they practice and how many people leave. “We have good data on entrance and little data on those leaving the specialty,” Mr. Salsberg said.

    Both allopathic and osteopathic numbers in emergency medicine have been growing, he said. “We will be looking at the level of interest. It is important for specialties like emergency medicine, which are now so attractive, to continue to be attractive.”

    The use of nurse practitioners and physician assistants, whose numbers have grown as rapidly as those of physicians, can make practice less stressful and lower the number of emergency physicians who need to be trained, Mr. Salsberg said. Some answers to these questions will come from focus groups and interviews with physicians.

    The changing organizational structure under which physicians work, which includes the growth and size of groups managing emergency medicine, will also be part of the study. “Are we likely to see efficiencies and new delivery models because we have larger organizations?” Mr. Salsberg asked. “Or will it discourage some emergency physicians with the larger corporatization of medicine? Are venture capitalists more likely to introduce efficiencies and policies to reduce demand or increase satisfaction on the part of practicing doctors? We will include questions about the effect of corporatization on practice. Do doctors feel more frustrated? Is there less control over practice?”

    An Uncertain Future

    Mr. Salsberg said his team will also look at demand to determine if there are enough EPs, he said, noting that emergency medicine popular wisdom is that demand will rise as will the use of emergency departments. The current uncertainty in health care, however, makes that difficult to study. Accountable Care Organizations and federal Medicare penalties were designed to reduce ED use. Will they really do that? “If we increase [insurance] coverage, will that increase emergency department use? If we decrease coverage, how will that affect use?” Mr. Salsberg asked.

    ED usage is also affected by social determinants of health, such as housing, nutrition, education, and jobs, which are crucial to keeping people out of hospitals. “It is important to do a comprehensive assessment of supply and demand to determine whether they have reached an appropriate capacity, should keep growing, or are overshooting the need, Mr. Salsberg said.

    “I don't expect to come out with a finding that we will need X number of emergency physicians or that we have too many,” he said. “There are many scenarios. I hope to provide indicators that the specialty can keep an eye on to tell relatively quickly what is playing out.”

    Unknown Variables

    Michael Brown, MD, MSc, the president of the Association of Academic Chairs of Emergency Medicine, which is under the SAEM umbrella and elected not to join the task force because of the cost, said they felt comfortable with SAEM's representative on the task force. “As an individual, I think most chairs would be supportive of the study,” he said. “We want to make sure that all the students and residents who choose our specialty have a job in the future. Why wouldn't we support a study like this?”

    Workforce projections are always difficult, however, because of unknown variables, he said. “AAMC [Association of American Medical Colleges] workforce projections say there won't be enough physicians in the future because of the growing elderly population,” Dr. Brown said. “That makes sense. When I work a shift in the emergency department, a lot of the patients I see now are elderly. They come in with falls and similar problems that seem to be a higher volume than what I saw 30 years ago.”

    The other side of the coin is that there are more and more extenders—midlevel practice providers, Dr. Brown said. “More and more of those are graduating and looking for work. A lot of health systems are using that workforce because it's more efficient and less expensive. Is that the dynamic? Where does that put future graduates? I don't know the answer. That's why I am very interested in the workforce study.”

    The growing number of emergency physician residency programs is also an issue that needs study, but “it may make the job opportunities more difficult for those who are graduating 10 years from now,” he said.

    “The reality is that most board-certified emergency physicians don't want to go to remote areas that really need those providers,” Dr. Brown said. “Many of those slots will never be filled by board-certified emergency physicians.”

    Those issues make the study more important, he said. “No matter how difficult, it's great to attempt to make projections so we can do the right thing for future patients and trainees.”

    Ms. SoRellehas been a medical and science writer for more than 40 years, previously at the University of Texas MD Anderson Cancer Center, the Houston Chronicle, and Baylor College of Medicine. She has received more than 60 awards, including the Texas Human Rights Foundation Award. She has been a contributor to EMN for more than 20 years.

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